If you are free around noon today, join my chat on the Washington Post web site, http://live.washingtonpost.com/obesity-treatment-and-health-care-reform-.html
If you are free around noon today, join my chat on the Washington Post web site, http://live.washingtonpost.com/obesity-treatment-and-health-care-reform-.html
If you are free around noon today, join my live chat on obesity at the Washington Post web site, http://live.washingtonpost.com/obesity-treatment-and-health-care-reform-.html
In 2003, a prestigious researcher, Jeffrey M. Friedman, called for a ‘War on Obesity, not the Obese.” A war on obesity, not the obese. [Science. 2003] – PubMed Result We seem, six years later, not able to make the distinction.
Elsewhere we have addressed various attacks on persons with obesity, rather than obesity itself. Medical experts, it seems, appear particularly unable to tell what is a war on obesity and what is a war on persons with obesity.
A ‘War on Obesity’ includes the same elements that have guided other, successful, approaches to health care problems, whether infectious diseases or chronic conditions. The elements are straight-forward: (1) educate the public and health professionals, (2) focus research on finding both the causes and effective interventions, (3) promote prevention, when possible, (4) intervene and treat those affected, (5) if relevant, strongly combat stigmatization and discrimination, as they are impediments to effectively treating and preventing the disease, and (6) consumer protection to stop the exploitation of worried people and their diversion into unproductive avenues of recourse. With obesity, in general, the federal government has only focused on educating the public and promoting prevention (although we still lack proven prevention strategies). All the other strategies have been not totally, but largely, neglected.
Identifying a “War on the Obese” requires a little work. It requires work because stigmatizing overweight/obese people is so ingrained in our culture. It starts early and does not stop. Shunning, embarrassing, ridiculing and penalizing persons with obesity is so ingrained in our society, we take it for granted. How do we recognize it?
Lets take Dr. Toby Cosgrove, CEO of the Cleveland Clinic, statements about hiring obese persons.
1. On August 12, 2009, David Leonhardt of the New York Times, wrote, “Cosgrove says if it were up to him, if there weren’t legal issues, he would not only stop hiring smokers. He would also stop hiring obese people. When he mentioned this to me during a recent conversation, I told him many people might consider it unfair. He was unapologetic.”
2. On September 6, 2009, Dr. Cosgrove was interviewed by Guy Raz on NPR:
RAZ: And you have argued that you would not hire people who are obese. Is that fair?
Dr. COSGROVE: No, I think that that was a quote that was taken out of an hour-and-a-half interview. And what I said was that we are concerned about the obesity problem, not about people who are obese.
3. September 9, 2009, Cleveland .com carried the story, “Clinics Dr. Delos ‘Toby’ Cosgrove defends remarks about not wanting to hire obese people.” Asked at an obesity summit at the Cleveland Clinic, organized by the clinic’s bariatric surgery program by Walt Lindstrom, founder of the Obesity Law and Advocacy Center in California, if he wished ‘he hadn’t said it.” The Dr. Cosgrove demurred and said his comment was meant “to stimulate discussion on the growing costs of obesity.” He said, “I think a lot of people misunderstood what the point was…I never considered not hiring obese people, but I think we have to do something bold to address the problem.” The article goes on, “Cosgrove opened his remarks at the Obesity Summit by highlighting the Clinics health and wellness initiatives. On the obesity front, the hospital has eliminated fried foods, removed soda and candy from vending machines and subsidized Weight Watchers and fitness programs for its 40,000 employees, he said. “In nine months, we’ve lost 110,000 pounds across the organization, which I think is an amazing tribute to the program.”
4. September 12, 2009: On a Wall St. Journal Health Blog, Dr. Cosgrove said, “it would be illegal to apply a similar standard (not hiring smokers) to people who are obese, because they’re protected by the Americans with Disabilities Act (ADA). He said, “I can’t decide that I’m not going to hire somebody because they are 400 pounds. We don’t hire smokers and that’s perfectly legal.” According to the blog entry, “Cosgrove questioned that rule, suggesting it could hinder efforts to lower the nation’s obesity rate. Dr. Cosgrove said, “We are protecting people who are overweight rather then giving people a social stigma.” The blog reports that the Department of Justice said that only morbid obesity can be protected by the ADA but only “if it substantially limits a major life activity in the past or is regarded as substantially limiting.”
5. On September 13, 2009, Connie Schultz, a Cleveland Plain-Dealer Pulitzer-prize winning columnist for her focus on blue-collar families and economics, wrote, “Apparently, it is now fashionable to bash the obese. For the sake of health care, you understand. Nothing personal.” Quoting Dr. Cosgrove remorse that “We are protecting people who are overweight rather than giving people a social stigma” Schultz states, “What, Oh, he must mean all those obese people bragging about the compliments from strangers, the big, welcoming grins on the faces of fellow airline passengers. Not to mention the parade of size-20 models on fashion runways. Yup, obesity is really popular in America. Who wouldn’t want to be called fat. Punishing obesity compounds the problem.”
6. September 14, 2009, Dr. Cosgrove apologized to employees of the Cleveland Clinic for any “hurtful” comments, stating, “My objective was to spark discussion about premature causes of death, but some of my comments were hurtful to our community. That was certainly not my intent, and for that I apologize.”
In Cleveland, 70% of adults are over their recommended weight. Obesity is more prevalent among women than men, greater among black adults and higher among older persons than younger ones as well as more prevalent among lower income persons.
The picture of obese persons in Cleveland is intriguing. According to the Center for Health Promotion Research, “Obese and non-obese Clevelanders did not differ in the reporting of adequate fruit and vegetable consumption.” The difference appears to be in physical activity with obese persons reporting less adequate moderate or vigorous physical activity. More than half of all Clevelanders reported not getting adequate weekly amounts of moderate physical activity. BUT, as the report notes, “Clevelanders who were obese were more than twice as likely to report having diabetes (17% vs. 7%) and nearly twice as likely to report having asthma (15% to 8%).” They also report more hypertension and high cholesterol that non-obese Clevelanders. Therefore, the reports notes, lower levels of physical activity were related to diabetes, hypertension, high cholesterol and heart attacks.
The report goes on to note that obese Clevelanders reported more use of nutrition classes and organized health promotion activities compared to non-obese residents. Fully 75% of obese Clevelanders are trying to lose weight. Of the 76% of Clevelanders who reported seeing a doctor in the past 12 months, only 16% were given advice about their weight! Obese Clevelanders reported using both diet and exercise compared to those who were not obese. And more obese persons used a diet- only approach, “a possible reflection of the mobility issues related to obesity, and the additional need for diet modification.” http://www.case.edu/affil/healthpromotion/Publications/Publications/Steps%20BRFSS%20Data%20Brief%20OBESITY%203.27.08%20FINAL.pdf
Dr. Cosgrove has apologized to his current employees saying he only wanted to talk about premature deaths due to obesity. If he is concerned about premature deaths due to obesity, he might address why does his health plan for employees cover bariatric surgery after a two year waiting period (http://www.clevelandclinic.org/healthplan/plan-cchs-caremanagement.htm#MedBenefitsCoverClarification), one of the longest in the country, and, for which, there is no medical justification?
Even though Dr. Cosgrove has apologized to his employees, does anyone in the hiring process at Cleveland Clinic not understand the boss doesn’t want to see so many fat people on staff? Would you hire an obese Clevelander and take them to meet the boss for the ‘Welcome aboard’ gesture? Not likely.
At the end of the day, there is no evidence that stigmatizing obese persons reverses or resolves the problem. Stigma and discrimination does not work and only increases the sum of human unhappiness. We need new therapies and we need physicians who want to help their patients, and, Dr. Cosgrove, we need positive leadership.
July 24, 2010
A review of the relationship between fruit and vegetable intake with adult and childhood obesity casts doubt on how strong is the relationship with weight management. The review was undertaken by TA LeDoux and colleagues from the Department of Pediatrics at the USDA/Agricultural Research Service Childrens’ Nutrition Research Center at Baylor College of Medicine.
They found that, after reviewing 772 studies, increased food and vegetable consumption (in conjunction with other behaviors) contributed to reduced adiposity among overweight or obese adults but no association was shown among children.
While the quality of the studies varied widely, the relationship between high fruit and vegetable consumption and low obesity among “was weak” and among children “unclear.”
The study can be accessed at Relationship of fruit and vegetable intake with ad… [Obes Rev. 2010] – PubMed result
In a separate study, doctors in Plymouth, United Kingdom following 202 children for 7 to 10 years, found that overweight preceded physical inactivity, not the other way around. As most childhood obesity interventions assume inactivity precedes obesity, this study, if validated, indicates a change in strategy to combat childhood obesity. See Fatness leads to inactivity, but inactivity does n… [Arch Dis Child. 2010] – PubMed result
May 11, 2010 First Lady Michelle Obama delivers report to eliminate childhood obesity White House Task Force on Childhood Obesity Report to the President
April 30, 2010
Gallup Survey of over 670,000 Americans finds obesity rates continue to rise. Americans Making No Progress on Obesity
March 31, 2010
Department of Health and Human Services addresses similarities between obesity and addiction. Common Mechanisms of Drug Abuse and Obesity, March 28, 2010 News Release – National Institutes of Health (NIH)
By Morgan Downey, J.D.
March 23, 2010
With Sunday’s vote in the House of Representatives, the long-awaited health care reform legislation is on track become law. A great deal has been written about health care reform during the past year but little attention has been paid to how reform might affect the obesity epidemic.
Obesity is the most prevalent, fatal, chronic disease in the United States. 68% of American adults are overweight or obese, constituting a majority of the US population. This Q&A is not intended to cover the entire scope of the health care reform legislation but only to explain how it is likely to affect persons with obesity and the future of the obesity epidemic. (N.B. At several points, the legislation incorporates recommendations of the U.S. Preventive Services Task Force (USPSTF) meaning that these recommendations become covered services. The USPSTF has two obesity specific recommendations at level B: one for screening for obesity and the second for intensive behavioral counseling. The intensive behavioral counseling could open the door for extensive new services.)
1. What does the bill do to help the millions of Americans with obesity?
If you have obesity, have a medical condition and have not had health insurance for six months, you will be able to purchase coverage through a temporary high risk pool. (The pool is ‘temporary’ until the health exchanges are implemented).
If you have obesity and receive Medicare or Medicaid, you will see more preventive services fully covered.
If you have obesity and employer provided health insurance several provisions may affect you.
A. If you have had claims denied because of a pre-existing condition (either obesity or an obesity-related co-morbid condition), you should have an easier time getting such claims paid starting in 2014.
B. If you have reached lifetime caps on coverage, within six months of enactment, insurers will be prohibited from placing lifetime limits on the dollar value of coverage and from rescinding coverage, except in the case of fraud. Insurance companies will also be prohibited from canceling policies on people who get sick. (These are called recissions and ‘height and weigh’ is one of the four most common health reasons for a recissions according to a December 2009 report from the National Association of Insurance Commissioners).
C. Six months after enactment, private, qualified health plans will have to provide, without cost-sharing, preventive services with an A or B recommendation of the U.S. Preventive Services Task Force.
D. More expensive “Cadillac” health plans will start being taxed in 2018. To the extent that these plans may provide coverage of bariatric surgery and related services, they may scale back.
2. Is it all good?
Briefly, yes and no.
If you have obesity and have employer-paid health insurance, you may be paying more – potentially a lot more-for it. While the new law will ban discrimination on the basis of health status, an exception exists whereby persons in an employee wellness program can be charged up to 50% of the value of their health insurance premium if they do not meet specific health criteria, such as weight.
Intensive behavioral counseling for obesity will become more available. Whether insurers will have to provide bariatric surgery or drugs for treating obesity will be decided by a Health Benefits Advisory Board which will make recommendations to the Secretary of Health and Human Services.
Third, the tax deduction for medical expenses will change. Currently, individuals can deduct unreimbursed medical expenses (including physician recommended weight loss costs) to the extent they exceed 7.5% of adjusted gross income. The threshold will rise to 10%. This potentially hurts individuals with multiple chronic conditions and/or high, unreimbursed medical costs.
3. Does Medicare coverage of obesity change?
Medicare beneficiaries would receive a comprehensive health risk assessment and a personalized prevention plan. Incentives would be provided to Medicare beneficiaries to compete behavioral modification programs.
Medicare’s current coverage of bariatric surgery does not change.
The ban for drugs to treat obesity under Part D continues in effect.
4. What about coverage of obesity in Medicaid?
Current state-by-state coverage in Medicaid for bariatric surgery and drugs to treat obesity should not change. (Medicaid may cover drugs for obesity if the state applies for a waiver from a prohibition in the Medicaid statute.)
The Medicaid program will go through its largest expansion since its inception.
If cost-sharing is removed for covered recommendations of the US Preventive Services Task Force (see above), state Medicaid programs will have their federal matching rates increased
The Secretary of Health and Human Services (HHS) is also instructed to develop preventive and obesity-related services for Medicaid enrollees, including obesity screening and counseling for children and adults. Each state is directed to develop a public awareness campaign to educate Medicaid enrollees regarding the “availability and coverage of such services with the goal of reducing incidences of obesity.”
HHS will develop incentives to encourage behavioral change in Medicaid enrollees.
A new state option will be developed for Medicaid, allowing enrollees with multiple chronic conditions to select a medical home.
5. What does the law do about childhood obesity?
While often overlooked, the expanding coverage includes providing health insurance to millions of children whose parents do not have coverage now. For the increasing numbers of children and adolescents with obesity, their related conditions, like type 2 diabetes and hypertension, will now be covered. Starting in 6 months, children cannot be denied coverage because of pre-existing conditions.
In addition to the coverage components, the law provides funding for a childhood obesity demonstration project.
6. What about prevention of obesity?
The bill establishes a National Prevention, Health Promotion and Public Health Council to coordinate federal prevention, wellness and public health activities and develop a national strategy to improve the nation’s health. The strategy is due one year after the enactment. A Prevention and Wellness Trust is authorized to carry out the national strategy.
A grant program is developed for 5 years to support the delivery of evidence-based and community based prevention and wellness service aimed at reducing chronic disease rates.
Under Section 4201, the Secretary of HHS shall develop a competitive grant program for states and local governments for “the implementation, evaluation, and dissemination of evidence-based community preventive health activities in order to reduce chronic disease rates, prevent the development of secondary conditions and address health disparities.”
i. This includes creating healthier school environments, including increasing healthy food options, physical activity opportunities, promotion of health lifestyle, emotional wellness, and prevention curricula.”
ii. Also included are “developing and promoting programs targeting a variety of age levels to increase access to nutrition, physical activity;”
iii. “assessing and implementing worksite wellness programming and incentives; working to highlight healthy options at restaurants and other food venues.
iv. Grantees must report changes in weight, nutrition, physical activity.
b. Section 4202(a) provides a health aging program. Grants are to be provided to states and local governments for the 55 to 64 year old population “to improve nutrition, increase physical activity.” Covered are screenings to identify those with risk factors for cardiovascular disease, cancer, stroke and diabetes.” Those identified with such risk factors are to be referred to clinical services.
c. Section 4202(b) provides for an evaluation and plan for community-based prevention and wellness programs for Medicare beneficiaries to reduce their risk of disease, disability and injury by making healthy lifestyle choices, including exercise, diet and self-management of chronic diseases.
7. Does the law affect research on obesity?
a. The bill establishes a non-profit Patient-Centered Outcomes Research Institute to identify research priorities and conduct research which compares the clinical effectiveness of medical treatments. This is effective on enactment.
b. Section 4301 provides for research on optimizing the delivery of public health services.
c. Section 399MM1 provides for studies of worksite health policies and programs. No part of such recommendations, data or assessments can be used to mandate requirements for workplace wellness programs.
d. Section 4402 also provides for effectiveness research of health and wellness programs for federal employees.
e. Under the reconciliation changes passed by the House of Representatives and on its way for approval by the Senate, the Administrator of the Centers for Medicare and Medicaid will identify the most cost-intensive services for Medicare which shall ‘inform’ research priorities within the Department of Health and Human Service to improve prevention, treatment or cure of such diseases and conditions.
8. What are the other parts of the bill affect obesity?
The Secretary of HHS is mandated to develop, within one month of passage, an education and outreach campaign regarding preventive health services. The campaign must address proper nutrition, regular exercise and obesity reduction. It is mandated that the Secretary develop a website for health care providers and consumers to provide science-based information on guidelines for nutrition, exercise, obesity reduction and specific chronic disease prevention. Another website is to be developed with a “personalized prevention plan tool. This would include determining individual disease risk, based in part on Body Mass Index.
a. Of particular value for persons with morbid obesity, Section 4203 provides for the removal of barriers to medical devices for individuals with disabilities. Under this provision, standards will be developed to ensure that medical diagnostic equipment used in physician’s offices, clinics, hospitals and other medical settings to ensure that the equipment is accessible to and usable by individuals with accessibility needs to allow independent entry to and use of such equipment.
b. Restaurants which are part of a chain of 20 or more locations doing business under the same name must disclose for ‘standard menu items’ the nutrient content including calories in the item with the suggested daily caloric intake on the menu as well as a drive-through menu board. Self-service items must also display the calorie information. Restaurants and others, such as vending machine operators, may voluntary register to be part of the program. Regulations must be issued within a year of enactment.
c. In some studies, breast-feeding has been found to be preventive for the development of obesity in the child. For breast-feeding women, employers with over 50 employees must a reasonable break time to express breast milk for one year after the child’s birth, each time the employee has a need to express the milk and a place, other than a bathroom that is shielded from view and free from intrusion. Employers need not provide compensation for such time.
d. The Secretary of Labor is authorized to set up a grant program for employer wellness programs. Behavioral change is encouraged which provides for altering employee healthy lifestyles through counseling, seminars, on-line programs or self-help materials. Obesity is specifically listed as a focus. Participation cannot be mandated or conditioned on obtaining a health insurance premium discount, rebate or other financial reward.
9. What is not in the bill?
A proposed tax on sugar-sweetened beverages is not in the legislation.
10. What next?
The bill is large and complex. Many issues, especially regarding inclusion of surgery and drugs in health benefit plans, be have to be resolved by regulations from the Department of Health and Human Services. For example, while the USPSTF recommendation for intensive behavioral counseling does not include frequency, intensity and duration. These will need to be specified.