Posts Tagged ‘Look Ahead’

Cancer and Obesity Explored

November 3rd, 2011

The Institute of Medicine’s National Cancer Policy Forum this week convened a two-day workshop, “The Role of Obesity in Cancer Survival and Recurrance.” So this is a good opportunity to re-visit the relationship between these two deadly diseases. Susan Gapstur of the American Cancer Society noted the growing list of cancers associated with obesity. For men, these include cancers of the colon, esophagus, kidney, colorectum, pancreas, gallbladder and liver. Women are affected by the same cancers as well as of the endometrium and postmenopausal breast cancer. Evidence is accumulating for an association with non-Hodgkin’s lymphoma, ovarian cancer in women and aggressive prostate in men. Obesity, she pointed out, is not the second (to tobacco) leading risk factor of cancer. Ominously, she pointed out we do not know what the health effects will be for the children now obesity who will obese for a lifetime.

Pamela J. Goodwin of the University of Toronto explored potential mechanisms in the progression to cancer including inflammation, adipokines, hyperinsulinemia, diabetes/diabetes drugs and sex steroids. She pointed to studies showing reductions in cancer risk with intentional weight loss of 20 pounds or more. Intentional weight loss and in… [Int J Obes Relat Metab Disord. 2003] – PubMed – NCBI and reduction in the relative risks of death and of cancer following bariatric surgery. Metabolic surgery and cancer: protective effects of b… [Cancer. 2011] – PubMed – NCBI.  Specifically, she showed the positive effect of intentional weight loss on breast cancer risk   Does intentional weight loss reduce canc… [Diabetes Obes Metab. 2011] – PubMed – NCBI and the impact of physical activity on improvements in insulin in breast cancer survivors Impact of a mixed strength and endurance exerci… [J Clin Oncol. 2008] – PubMed – NCBI.

Bruce Wolfe of the Oregon and Science University and a bariatric surgeon reminded the participants that the Swedish Obesity Study found the reduction in mortality after bariatric surgery was greater for cancer than for cardiovascular events Effects of bariatric surgery on mortality in Sw… [N Engl J Med. 2007] – PubMed – NCBI. In a Utah study, bariatric surgery reduced deaths from cancer by 60% compared to a 48% reduction in cardiovascular events. Long-term mortality after gastric bypass surgery. [N Engl J Med. 2007] – PubMed – NCBI

Rachel Ballard-Barbash of the National Cancer Institute, who has been a leader in exploring the obesity-cancer connection for many years, moved the discussion to look at the co-morbid conditions of obesity and their relationship to cancer mortality, including renal disease, congestive heart failure, cerebrovascular disease, citing A refined comorbidity measurement algorithm fo… [Ann Epidemiol. 2007] – PubMed – NCBI

Patricia Ganz of the UCLA Schools of Medicine picked up the point and explained that about half of all deaths of breast cancer survivors are due to causes other than breast cancer. She recommended prevention of weight gain and/or weight loss in those breast cancer survivors who are obese. 

Thomas Wadden described the non-surgical approaches to weight loss used in the Diabetes Prevention Program and the LOOK Ahead study and the contribution of intensive behavioral counseling to reduction in comorbid conditions associated with obesity

Some of the workshop’s presentations are on-line at Workshop on the Role of Obesity in Cancer Survival and Recurrence – Institute of Medicine. Watch that site for future information on a publication from the workshop.

The Obesity Paradox Explained

October 7th, 2011

The “obesity paradox” refers to a phenomenon in which overweight and obese patients with established cardiovascular disease have a better prognosis than normal weight patients. This has been a controversial finding in several studies, indicating to some that weight loss is worse than weight gain. Now, researchers from the Veterans Affairs Palo Alto Health Care System, examined 3,834 male vets. They did find that weight loss was related to higher mortality and weight gain was related to lower mortality, compared to stable weight over 7 years. 

However, 60% of the deaths in the weight loss group were attributable to conditions associated with muscle wasting, including cancer and heart disease. These conditions arose during the seven year period. This study underscores that the obesity paradox may be explained by the distinction between intentional v. unintentional weight loss. As the authors note, clinically supervised intentional weight loss has shown extensive benefits including lowers incidence of cardiovascular events, better overall survival, marked reduction in the metabolic syndrome, inflammatory markers, lipids, prevalence of hypertension and better glucose tolerance. The obesity paradox and weight loss. [Am J Med. 2011] – PubMed – NCBI

 Even very obese adults can improve their cardiometabolic risk factors. Researchers of the Louisiana Obese Subjects Study (LOSS) found most parameters improved with 5% weight loss or more among 390 extremely obese men and women, followed for one year.  The intervention group was under primary medical care, using meal replacements, weight loss medications, especially sibutramine and behavioral counseling. Those in the intervention group lost an average of 13% of their weight while the ususal care group lost an average of 0.9%. 20.7% of participants had substantial weight loss (10%-19.9%) and 15.4% lost over 20%.  There was a “precipitous” decrease in fasting plasma glucose among patients with type 2 diabetes who achieved at least modest weight loss. Systolic and diastolic blood pressure decreased inconsistently. With modest weight loss, patients achieved 22% improvement in triglyceride levels. Only 53% of subjects stayed in the program for evaluation at one year. Incremental weight loss improves cardiometabolic ri… [Am J Med. 2011] – PubMed – NCBI

 A similar result has been observed in severely obese subjects in  the Look AHEAD trial. Effectiveness of Lifestyle Interventions for I… [Diabetes Care. 2011] – PubMed – NCBI

Medicare Urged to cover Intensive Counseling

September 28th, 2011

As we announced before, the Centers for Medicare and Medicaid Services is evaluating   including intensive behavioral counseling for adults with obesity as a Medicare benefit. Below are comments we just filed with Medicare. (The comment period closes September 30, 2011)  Readers still have time to submit their own comments.

Sarah McClain, MHS
Lead Analyst
Coverage and
Analysis Group
Centers for Medicare and Medicaid Services
Mail Stop C1-09-06
7500 Security Boulevard
Baltimore, Maryland 21244-1850
 

Dear Ms. McClain,

 The proposed coverage of intensive behavioral counseling of adults for obesity is both indicated by its endorsement by the United States Preventive Services Task Force , subsequent literature, and two studies published in the last month.

 

The Look AHEAD study has focused on the benefits of lifestyle changes to achieve weight loss in overweight/obese participants with type 2 diabetes. The study population which received intensive lifestyle intervention (such as that contained in the proposed decision memorandum) obtained superior results to those receiving usual care (diabetes support and education.) At year 4, there was a 4.7% reduction from initial weight in the intensive lifestyle group compared to 1.1% in the usual care group. 46% of the intensive lifestyle group lost more than 5% of initial weight and 23% lost more than 10%. (The usual care group saw 25% lose more than 5% and 10% lose more than 10%.) 

As these results would predict, the intensive lifestyle group had significantly greater improvements in glycemic control and several markers of cardiovascular disease risk.  

As with the Diabetes Prevention Program, the study’s oldest participants, 65-74 years of age, lost significantly more weight than younger counterparts at all 4 years, and reported lower daily caloric intake, higher physical activity and overall greater adherence to the behavioral program. (Wadden TA, Neiberg RH, Wing RR, et al, Four-Year Weight Losses in the Look AHEAD Study: Factors Associated with Long-Term Success, Obesity (2011) 19;10: 1987-1996.) 

Thus, it appears that Medicare could ‘look ahead’ with some confidence that the proposed benefit can result in immediate health improvements to Medicare beneficiaries.

 

These health improvements can be economically quantified, although that is not necessary for the purposes of National Coverage Determinations. Recently, Dr. Kenneth Thorpe reported that a 10% reduction in weight in persons with obesity  age 60-64 could provide Medicare with savings of $1.8 to $2.3 billion over ten years and even more if overweight pre-diabetic adults were included. (Thorpe KE, Yang Z, Enrolling people with prediabetes ages 60-64 in proven weight loss program could save Medicare $7 billion or more. Health Affairs 2011 Sep; 30(9):1673-9)  While the study participants did not achieve the 10% criteria, their remarkable results indicate a significant cost saving to the Medicare program could be achieved.

For these reasons, the Centers for Medicare and Medicaid Services should not only implement the proposed decision memorandum for Medicare beneficiaries but to explore ways in which such intensive behavioral counseling for obesity may be utilized by as many obese beneficiaries as possible. This would include a two-prong educational campaign. The first prong would be directed to the appropriate health care professionals to make them aware of the benefit and how to achieve competency in intensive behavioral counseling. The other prong would be directed at Medicare beneficiaries to make them aware of the new benefit and possibilities of successful weight management.

 

 Sincerely,

Morgan Downey,

Editor & Publisher, Downey Obesity Report

Washington, D.C.

 

Intensive Counseling, State Data and Incentives- What’s new

September 29th, 2010

September 29, 2010

Look AHEAD, an NIH funded long term study of life style intervention on weight and cardiovascular risk factors has released its 4 year findings. One arm of the study received intensive lifestyle counseling; the other arm received usual dietary counseling. Averaged across the four years, body weight was reduced in the intensive group by 6.5% compared to 0 .88%, along with improvements in fitness, hemoglobin A1c, systolic and diastolic blood pressure, HDL cholesterol and triglycerides. Some of the gains decreased over time as one would expect but were still significantly better at the four year follow-up. See, Arch Intern Med — Abstract: Long-term Effects of a Lifestyle Intervention on Weight and Cardiovascular Risk Factors in Individuals With Type 2 Diabetes Mellitus: Four-Year Results of the Look AHEAD Trial, September 27, 2010, The Look AHEAD Research Group 170

George Washington University School of Public Health and Health Services has released new data on obesity coverage under the Medicaid program, state employee coverage and mandates for obesity coverage, as well as their new study on the personal costs due to obesity. See Health Policy | School of Public Health and Health Services | George Washington University

The American College of Physicians has released a paper, Ethical Considerations for the Use of Patient Incentives to Promote Personal Responsibility for Health: West Virginia Medicaid and Beyond. The paper addresses evolving wellness programs which involve “incentives” or “penalties,” depending on one’s point of view. The paper cautions, “”motivating behavior change is much more complex than can be accomplished with a single strategy and requires both an individual commitment to health as well as societal collaboration to eliminate barriers. The College adds that such programs “must be designed to allocate benefits equitably;  must not include penalties.”    See,       http://www.acponline.org/running_practice/ethics/issues/policy/personal_incentives.pdf

Goals

September 27th, 2009

5-10% is a realistic and achievable goal for weight loss Weight-loss outcomes: a systematic review and meta…[J Am Diet Assoc. 2007] – PubMed Result

What interventions should we add to weight reducin…[J Hum Nutr Diet. 2004] – PubMed Result

The weight stability approach Obesity in primary care: evidence for advising wei…[Br J Gen Pract. 2008] – PubMed Result

Do physicians support 5-10% reduction? What do physicians recommend to their overweight a…[J Am Board Fam Med. 2009 Mar-Apr] – PubMed Result

Look Ahead trial shows promising results from intensive weight loss counseling One-year weight losses in the Look AHEAD study: fa…[Obesity (Silver Spring). 2009] – PubMed Result

5% reduction needed to improve metabolic parameters Degree of weight loss required to improve adipokin…[Metabolism. 2009] – PubMed Result

Federal Government

September 27th, 2009

Federal Programs on Obesity

For an excellent overview, see http://www.stopobesityalliance.org/research-and-policy/research-center/gw-research/ and F as in Fat: How Obesity Policies Are Failing in America 2008 – RWJF

National Institutes of Health

NIH is the preeminent research organization in the United States and the world and have a number of research programs related to obesity.

Weight Information Network has many fact sheets, also available in Spanish Welcome to WIN – The Weight-control Information Network

What is NIH spending on obesity? A projected $664 million. NIH Research Portfolio Online Reporting Tool (RePORT) – Estimates of Funding for Various Research, Condition, and Disease Categories (RCDC)

What are the specific grants now in process? NIH Research Portfolio Online Reporting Tool (RePORT) – RCDC Project Listing by Category

What is their plan to address obesity? Obesity Research at the National Institutes of Health (NIH)

Information on applying for grants. http://grants.nih.gov/favicon.ico

Clinical trials Home – ClinicalTrials.gov

Some particular projects:

Longitudinal Assessment of Bariatric Surgery Longitudinal Assessment of Bariatric Surgery

Clinical Nutrition Research Units WIN – Research – ONRCs and CNRUs

Research Opportunities Obesity Research at NIDDK : NIDDK

Advisory Groups Clinical Obesity Research Panel (CORP) : NIDDK

NIDDK Office on Obesity Research Office of Obesity Research : NIDDK

Look Ahead Trial Action For Health in Diabetes (Look AHEAD) : NIDDK

Food and Drug Administration (FDA)

The FDA has several responsibilities when it comes to obesity, including nutrition labeling and approval of drugs and devices

Calories Count: The 2004 plan of FDA to address obesity FDA/CFSAN – Calories Count: Report of the Working Group on Obesity Q&A Questions and Answers – The FDA’s Obesity Working Group Report

The Keystone Report on Away from Home Foods Calories Count and Keystone Report

Consumer information on reading the nutrition label. Make Your Calories Count

Department of Agriculture

Women Infants Children program of the USDA is a program of providing grants to states for nutrition education and support for low income pregnant, breastfeeding or post partum women WIC

Food and Nutrition Information Center Food and Nutrition Information Center

General Information on obesity General Information and Resources : Weight and Obesity : Food and Nutrition Information Center

Consumer Nutrition Information Weight Management : Nutrition.gov

Internal Revenue Service (IRS)

While the IRS is not considered a health agency, it does provide that taxpayers may use the medical deduction for expenses related to weight loss when a physician makes a recommendation of weight loss. Publication 502 (2008), Medical and Dental Expenses

Surgeon General

Surgeon General Richard Carmona on Obesity The Obesity Crisis in America

Surgeon General’s Report to Prevent and Decrease ObesityThe Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity

Transcript of meeting where Surgeon General David Satcher decided to issue Surgeon General’s Report on Preventing and Overcoming Obesity: http://www.health.gov/hpcomments/council4-23-99/focus.htm

Earlier Surgeon General Reports on Nutrition and Health The Surgeon General’s Report on Nutrition and Health (1988) and Physical Activity Physical Activity and Health Executive Summary

Center for Medicare and Medicaid Services (CMS)

In 2004, CMS dropped language from its policies that obesity was not considered a disease. 2004.07.15: HHS Announces Revised Medicare Obesity Coverage Policy. A Deletion Opens Medicare To Coverage for Obesity – The New York Times

Subsequently, it convened an advisory panel to consider expanding or restricting medicare coverage of bariatric surgery which considered a summary of the evidence on the surgery’s safety and effectiveness. http://www.cms.hhs.gov/FACA/downloads/id26c.pdf

The outcome of the advisory panel was very favorable and, in 2006, official coverage policy was changed and expanded. Centers for Medicare & Medicaid Services

Disability

EEOC Policy on obesity EEOC Informal Discussion Letter

EEOC definition of “disability” Section 902 Definition of the Term Disability

6th Circuit Court of Appeals denies ADA claim based on morbid obesity. Read the full decision in EEOC v. Watkins Motors. http://www.ca6.uscourts.gov/opinions.pdf/06a0351p-06.pdf

Through the Social Security Administration, individuals who are morbidly obese and have cardiovascular, respiratory or musculoskeletal problems may quality for disability.

See: Disability Doc – Examining Social Security Disability – Obesity and Disability

Centers for Disease Control and Prevention (CDC)

The CDC has numerous fact sheets and guides. Where appropriate, they are incorporated into more specific sections of the site.

To see all the CDC resources available, go to Obesity and Overweight: Topics | DNPAO | CDC

Agency for Healthcare Research and Quality (AHRQ)

AHRQ funds research, especially on the translation of basic research into clinical practice, improvements to clinical care and a number of evidence-based guidelines. Relevant guidelines are included in the treatment or health effects sections. AHRQ is a leader in Comparative Effectiveness Research and obesity is one of their major conditions of interest.

See Agency for Healthcare Research and Quality (AHRQ) Home Page

Medicaid

Morbidly obese patients often return to work after gastric bypass surgery Return to work after gastric bypass in Medicaid-fu…[Arch Surg. 2007] – PubMed Result

Veterans Administration

Learn about the VA programs in weight management at MOVE! Home

Department of Defense

Information on the military’s Tricare program and weight management can be found at The TRICARE Blog