A Lifetime of Exercise Won't Prevent Weight Gain

Does sticking to a regular exercise program year after year, decade after decade, keep you from gaining weight? According to a study just published in JAMA, the bad news answer is no. The only good news is that regular exercise is associated with less weight gain.

Sound disappointing? To millions of Americans that think they can regularly make up for yesterday's second donut with today's treadmill session, it should be. And to the processed food industry, it's an inconvenient truth.

The Coronary Artery Risk Development in Young Adults (CARDIA) multi-center study started in 1985. It enrolled 5115 young adult volunteers ranging in age from 18 to 30. Participants returned at 2, 5, 7, 10, 15 and 20 years. At each review, subjects were asked about their overall activity and exercise levels (for example, jogging, cycling, swimming, dancing or home maintenance). Those data were plugged into a simple scoring table and points were awarded that, depending on the individual activity, ranged from 108 to 288. They were then added up to yield a total score. To put things into perspective, the DMCB took the time to access the JAMA web site to find out more about the scoring. Doing home maintenance plus regularly playing golf led to 254 points. If jogging was included, the score jumped to 532 points. The authors estimated that meeting the U.S. government's activity guidelines would result in about 300 points.

To correlate the CARDIA score with body mass index, the authors grouped the study population by gender into "high," "medium" and "less" tertiles. To be assigned a tertile, participants had to score into one of the three tertiles for 2/3 of their visits over the 20 years of the study.

Men at the higher levels of exercise consistently scored greater than 608, moderate was 340 to 607 and less was below 340. Higher exercising women were greater than 398, moderate was 192-397 and less was below 192. Persons who failed to keep the "two thirds rule" were lumped into an "inconsistent" category.

At the 20 year mark, there were 3554 individuals with usable data. After controlling for age, race, educational level, tobacco use, alcohol use, food intake and starting BMI, increasing exercise levels were associated with the a lower rate of weight gain. For men, higher or moderate exercise was associated with a per year BMI increase of .14 to .15, while lesser exercise led to annual BMI increases of .20. For women, the BMI at higher tertile levels of exercise increased at a rate of .17 per year versus .25 for moderate and .30 for lesser. Everyone started out at a BMI of about 24 and over the years it increased to the 28-30 range. You can get an idea of what different BMIs look like here.

What can the DMCB conclude?

While it's a bummer, the study only confirms what has been known for years: exercise by itself does not prevent weight gain and cannot be used to decrease weight. All things being equal however, (and this study controlled for dietary intake) exercise by itself can blunt weight gain. Over twenty years, that can make the difference between being "overweight" (BMI less than 30) and being "obese" (BMI equal to or greater than 30). That's good from a public health perspective, but for us individuals, it's not going help us look good at the beach.

While it would appear that men seemed to need to exercise at a higher level compared to women to gain the benefit, the small print in the study showed no difference in the degree of weight gain between higher and moderate lifetime exercise levels. The authors noted that persons meeting the government's activity guidelines also gained less weight compared to the lowest group but the DMCB wonders if being in the 340-400 range (supplementing, say golf and housework with something else, like jogging, swimming or cycling) for both genders is where most of the benefit lies. For men, exceeding that level didn't confer any additional protection.

Weight and Mortality: Fear Not, It's Not That Bad

The Disease Management Care Blog is surrounded by death and destruction. Sea water will soon be lapping on its property line, radiation is in its airports, toxic mercury is in its compact fluorescent bulbs, killer E. coli is in its ground meat, invading Staph is on its skin and now the Grim Reaper is lurking in it's chubby abdominal paunch. At least that's the apparent message from this article published December 2 in the New England Journal. Mainstream media is spreading that alarm. Fat can shorten life. Fat is risky. Fat leads to higher mortality. Yikes!

But there's nothing like looking at the original article and underlying data to quell its panic. The authors pooled data from 19 observational population studies taken from the National Cancer Institutes's "Cohort Consortium," resulting in a database of 1.46 million adults. The median age was 58 years and the median body mass index (BMI) was slightly elevated 26.2 with a range at went from 15 to 50. The tricky part in the study was to statistically neutralize or exclude the impact of other determinants of mortality, like physical activity, past or current tobacco use, alcohol consumption, educational achievement and marital status. The authors then calculated hazard ratios for different categories of BMI. Hazard ratios can be thought of as measures of relative risk compared to a reference group.

In this study, persons with a BMI between 22.5 to 24.9 had the lowest mortality, so they were considered "one." Among non-smokers, the hazard increased as BMI increased: it was 1.03 if the BMI ranged between 25 to just over 27, 1.17 if the BMI was 27.5 to 29.9, 1.39 if it was 30-34.9, 1.98 (in other words, it almost doubled) if it was 35-39.9 and 2.92 if 40-49.9.

Sounds awful, right?

But while the hazard ratio from being fat can increase by "17%," or "39%" or "double," the DMCB asks: what does that mean, exactly? If in relative terms, if the death rate at baseline is one in a thousand and it "doubles" to two in a thousand, it that bad? On the other hand, if the death rate is one in ten and it doubles to two in ten, that sounds a lot worse. Which is it?

In the DMCB's read of the Journal article, it couldn't get a fix on this absolute hazard or risk of death. However, it took comfort in this graph using the same sort of data that appeared in a Lancet Letter to the Editor. As weight increases, yearly mortality "steeply" increases from about 5 per thousand (that's less than 0.5%) to about 8 to 9 per thousand (as in less than 1%). For smokers, the numbers are worse, but still in the range of 1-2%.

In other words, death rates can double with weight gain, but in absolute terms, the personal risk to the overfed DMCB seems to be pretty small. The "hazard ratio" increases 30 to 100%, but the absolute odds that DMCB will survive the year along with the rest of its skinny colleagues is very very good.

Better, says the DMCB, to relax. That's why, when it goes local mall for some holiday gift shopping and stops at the food court this season, it will fear not. Better, it says, to enjoy its shake, pizza and fries and celebrate.

The Playbook Used by the Food & Beverage Industry to Avoid All Blame for the Obesity Epidemic, and What Disease Management Can Do

The Disease Management Care Blog thinks that the disease, care and population health management providers deserve a lot of credit for leading the way in our national battle against obesity. This industry "gets it." It's more than just "consumer education" and go-see-your-PCP about starting a diet. While those elements are certainly necessary, disease management also knows about consumerism, engagement, overcoming barriers, behavioral theory, relationships, life-style management, being realistic and follow-through. These vendors are getting far more savvy about studying outcomes and using those data to continuously improve. They are participating in coalitions, joining public health initiatives, off-loading overburdened physicians, establishing partnerships, leveraging community resources, and formulating a compelling business case. They can do all that and still end the day with a tidy profit.

The DMCB also figures the disease management (DM) industry is also well aware of the cynical speciousness of the food and beverage industry's public posture about obesity. At the same time it's intentionally packing calories and salt into servings are both unhealthy and excessive, the food and beverage manufacturers have somehow escaped being lumped with tobacco and pharma. Something is terribly wrong with this picture.

That's the topic of an October 6 JAMA paper by Jeffrey Koplan and Kelly Brownell aptly titled "Response of the Food and Beverage Industry to the Obesity Threat." It's worthwhile reading for those combating the obesity epidemic. It gives special insight on how that industry combats greater scrutiny and regulation as well as why overweight patients desiring to lose weight can be so misinformed. This is important to know about so that patients can be better educated, know what they're up against, overcome barriers and better manage life-style choices.

Drs. Koplan and Brownell's report on the food industry's strategy is summarized below for DMCB readers that may not have full access or lots of time:

Associate with a widely respected health organizations: this gives the casual observer that the industry's wares are good for you.

As the DM industry's role in the crusade against obesity grows, it should probably resist any affiliation with the businesses that profit from making people fat.

Associate with a widely respected connotation: this generates the impression of wholesomeness. The authors mention featuring svelte exercisers on the packaging and in TV commercials, but the DMCB thinks claims of being "green" are also part of the mix.

Ironically, a disease management care plan with overemphasis on exercise as a cure for obesity is playing right into the food and beverage industry's hands. That has a role to play, but the key thing remains smart food choices and long term calorie restriction.

Reframe the issues: instead of addressing the merits of caloric excess, the idea here is to move the focus onto caloric neutrality (a serving of broccoli can be equal to a side order of fries), "in versus out" caloric balance (hence the intrusion of exercise as a fix for being fat; think about that the next time you watch Biggest Loser), keeping collateral societal costs out of the discussion ("even though half of all obesity related costs are paid for with public funds") and trumping free markets (we have a constitutional right to be fooled into making bad decisions).

At the individual patient level, part of the strategy of coaching is to help patients keep their eye on the caloric ball. Thanks to its growing visibility at various policy-making levels, the DM industry should continue to step up and shine a light on those collateral costs and take a greater leadership role in figuring out ways to help people make right decisions. Kudos, by the way, to the Care Continuum Alliance for doing its part.

Deceptive advocacy: this is setting up faux grass roots groups that are allegedly against regulation and taxation.

Hey, it's free speech. The DM industry needs to fight fire with fire.

Deceptive science: consisting of sponsoring biased studies and creating hollow self-regulating standards based on those biased studies.

The DM's industry's long tradition of tapping into vetted guidelines has been an important counterweight in its care for millions of Americans. It needs to stick to that tradition and educate policymakers and politicians about what works - and what doesn't.

Product formulation: it may still be the same air-filled puffs of fructose and fat, but add some vitamins or fiber and "voila!" the overwhelming impression is that it's now good for you.

In its day to day interactions, this and other attempts at caloric camouflage need to be countered one patient at a time. It may be that no patient coaching is complete without addressing that particular falsehood.

Go on the attack: it's not enough to deny any harm. Rather, get a stable of loyal talking-head scientists, lobby heavily, fight every unfriendly public health measure and label opponents as enemies.

The DMCB is looking forward to the day when a member of the DM industry is attacked by the food and beverage industry or one of its lackeys. They we'll know we're getting somewhere.

The U.S. Surgeon General Tackles Obesity.... NOT

Remember when we had, for example here and here, U.S. Surgeon Generals that really shook things up? That's not the situation today. Vice Admiral Regina M. Benjamin, M.D., M.B.A has issued forth with a milquetoast style public appearance to promote a "Healthy and Fit Nation" report that's stuffed with more bland nostrums than the creme in a supermarket donut.

Despite its admiration for for Dr. Benjamin, the Disease Management Care Blog is disappointed over her recitation of the usual anti-obesity bromides: eat fewer calories, improve food choices, promote physical activity, bring physical education/playtime back to schools, create worksite wellness programs, engage the physicians and establish healthy communities. Public health experts have been reciting the same thing for years without effect.

Here's some unasked-for advice DMCB to our Surgeon General:

While you serve at the political pleasure of the President, you also have the benefit of Senate confirmation, the stature of your office and the confidence of the American people. Why not use it?

To wit, you could point out:

....there are many reasons to not listen to Mike Hukabee, but there's one reason why he has some credibility on the topic. You need to announce that your leadership on the topic will start at the top. 'Nuff said.

....since the U.S. government happens to also be a large employer, it could be doing much more to lead the way in combating workplace obesity. The silence in this area is deafening.

....that the risk of obesity should be into perspective. Shouldn't we be less irrational about our bodies and more realistic about what can be achieved?

.... that there is merit to the idea of harnessing private-public entrepreneurship with competitions aimed at sustainable but challenging weight loss goals in schools and communities.

.... there may be something to an enlightened soup nazi approach to worksite wellness.

.... that the rationale of aggressively taxing sugared beverages makes sense and that you stand against the food industry's actions in this area.

.... that banning internal combustion engines within a mile of our schools is an intriguing idea.

.... that there may be merit to conducting expeditiously conducted pilot programs to determine the role of medications to combat obesity, especially in children. The DMCB doesn't like the idea either, but since good comparative effectiveness research indicates just diet and exercise has little impact, what other options are there? Bariatric surgery?

....that remotely positioned disease management that engages persons using the latest advances in behavior change is an important part of the solution.

The DMCB admits to bringing up some controversial topics. The point is that it came up with these in an afternoon while working on other stuff. Our Surgeon General can report on these and other options in the battle against obesity. All she needs to do is to take a cue from her more famous predecessors, step outside the political safe zone, invest more effort in thinking about breakthrough/high impact approaches and challenge Americans to actually do something fer cryin' out loud.

An Intense Program to Reduce Overweight and Obesity Among Children: Minutes From a Disappointed School Board

Corpulencia School District

Business/Work Session Minutes

June 28, 2010

Call of Meeting to Order: Vera Lardy called the meeting to order at 6:03 PM

Roll Call of Board Members: The following members were present: Max Podgy, Seymour Gross and Anita Diet. The following members were absent: Barry Atric (in the hospital getting surgery)

Action Items: The Board considered instituting a school based program aimed at reducing the prevalence of obesity and overweight among the 6th grade school population. In particular, it examined a state-of-the-art program that was reviewed in the New England Journal of Medicine. This was a huge two year study involving 42 Hispanic/Black or highly Federally food subsidized school districts (half of which were assigned to an intervention group, the other served as controls). While Board Members were encouraged to read the protocol for themselves, Ms. Lardy summarized the study. The 21 intervention schools 1) improved the food choices in the cafeteria, vending machines and even fundraisers, 2) promoted exercise targeting specified amounts of time designed to increase the heart rate to 130, 3) used a behavioral intervention to encourage lifestyle choices and 4) reinforced it all with posters and public address message scripts.

Board members unanimously voiced support for the program until they found out how the intervention schools fared compared to the controls. BOTH the intervention and the control schools had a decrease in the prevalence of overweight and obese children. There was an absolute decrease of about 4% in both groups that failed to show a statistically significant change favoring the intervention group.

Statistical significance was achieved in reducing the prevalence of just obesity. The intervention schools went from about 30% to 24.6% while the control groups went from about 30% to 26.6%. Because the study was also aimed at reducing the likelihood of future diabetes in these children, the authors also studied changes involving insulin levels and blood glucose levels, most of which also failed to achieve statistical significance.

Mr Podgy shared his impression that much of the news media makes it sound like eating more veggies and getting more exercise will practically cure obesity. 4% is disappointing. Mr. Gross said that Ms. Obama's campaign sure tastes great but is less filling in terms of a satisfying return on investment for taxpayers; would they be satisfied with a 4% rate? Ms. Diet observed that combating obesity will take years, but perhaps the prevalence of obesity has leveled off. Everyone agreed that in the current fiscal environment, the likelihood of funding intense school-based programs like this, given the success rate, is pretty low.

Adjournment: On that depressing note, Mr. Gross made a motion to adjourn and it was seconded by Ms. Diet. The meeting was adjourned over soda and donuts.

(any reference to any persons living or dead or any school boards, except for the part about soda and donuts is completely unintentional)

Just Avoid Dessert and Increase Your Activity Level - That's the Cure for Being Fat...NOT

If you treat yourself to a chocolate chip cookie every day, what does that daily dose of 60 calories mean to your long term weight? You would think, all things being equal, that that calorie load would translate into tens of extra pounds over a lifetime. So, while you were svelte when you were in your twenties, that regular cookie intake makes you fat when you are in your fifties. Policy, therefore, should be directed at all the little stuff, like sweetened beverages, portion sizes and moderation, right? If we all only learned to eat a little bit less, especially as children, we'd all be skinny as adults? Goodbye obesity epidemic?

The Disease Management Care Blog liked this idea because it eats cookies rarely. On the other hand, it knows it remains stubbornly overweight. What gives?

Not so fast, say Martijn Katan and David Ludwig with an explanation in the January 6 issue of JAMA. It turns out that human metabolism is wired to expend greater energy as weight goes up, and to preserve energy as weight declines. Not only do energy requirements change as a function of moving fewer or greater pounds, there are also countervailing changes in hormone levels, nervous system activity and the efficiency of the body's energy conservation.

As a result, they write, 'small changes in lifestyle would have a minor effect on obesity prevention.' This means significant and sustained weight loss fall well outside the ability of most persons who are not actively and agressively dieting on a daily basis and even then, most are destined to gain it all back anyway.

To address the societal imbalance between energy input (food calories) and output (the activities of living, supplemented by exercise), exhortations to avoid that cookie and go for a daily walk are unlikely to make Americans generally skinnier. Instead, we're going to need to reconsider the idea that minor painless adjustments in diet and exercise are the fix for the obesity epidemic. We may need to think about getting real with better attention to calorie content, increasing appropriate government regulation, getting public health involved, reexamining agricultural policy and changing the environment to promote much higher levels of physical activity.

Image from Wikipedia

Obesity: Are We Dealing With A Growing Addiction? Implications for Population Health Management Strategies

The Disease Management Care Blog welcomes Rose Maljanian, who is President & CEO of Strategic Health Equations, LLC. She has 25 years of health care experience and has served in senior leadership roles in managed care, specialty care management and health delivery systems

By Rose Maljanian

Today, yet another important and credible set of data from America’s Health Rankings have been released. It is telling us that obesity is on the rise and that the costs and health implications associated with it will devastate the financial viability of the US health system as we know it. The Urban Institute also recently released a report calling for more focus on obesity in developing health policy so that we can make headway on curbing this alarming trend.

In response, disease management and population health management companies, along with their contracting health plan, government and employer partners, are hard at work designing and deploying obesity programs. These are offering individualized health coaching to address the issue and in most cases providing incentives versus cost to participate. These programs have demonstrated some success, but have few resources in the way of evidence based practice (EBP)guidelines. They have yet to demonstrate definitive results such as those from the EBPs for diabetes or coronary artery disease medication management. Further, these programs and their staffs are fighting gravity when it comes to what we are calling behavior change because of the environment, social networks/norms, and the lack of serious medical attention often given to obesity.

If we are going to make serious headway, we need to abandon the notion that weight is a vanity issue or that obesity is solely a lifestyle choice that we as a society can all live with. While the evidence to support obesity as a condition of addiction is limited to nonexistent, the parallels to other addictions such as drug and alcohol are undeniable.

We now have evidence that fat cells, particularly those deposited centrally, are active metabolic (versus 'dormant') cells. These cells release chemicals that disrupt the normal hunger center in the brain and cause cravings even when a negative calorie balance does not exist. Thus, people consume larger than needed serving sizes high in fat and calories content while fully understanding that each bite puts them in further jeopardy of early disease and death. In compromised economic times, weight gain may put further stress on families due to the expense of food or need for new clothing because of size change. Their impairments can limit their ability at work or render them unable to perform certain types of work, which only further limits their economic future. Social activities which they previously enjoyed with friends, children and grandchildren may now be foregone or at least put at risk. The problem can contribute to compromising a relationship and even a marriage.

Continuing this negative behavior when it has these kinds of life consequences are a classic sign of addiction when it comes to alcohol and drugs.

Most would agree that allowing such adverse sequelae to build defies logic. Few people would say that an individual would consciously and regularly choose an extra cupcake or cheeseburger over their ability to work, achieve economic stability or success, enjoy time with their loved ones or be available and capable to help others in need.

Since today there are no magic bullets in surgeries or drugs that are suitable for the large numbers of people that need our help, through research we need to build an evidence base to support effective treatment that addresses the possibility that we are dealing with a sort of addiction of enormous magnitude in a very challenging circumstance and where abstinence from the “substance” altogether is not an option.

In the meantime, steps to address obesity as a serious medical and behavioral issue with addiction-based approaches are warranted. Providers can help by formally diagnosing the problem, providing treatment options and doing everything in their power to help people take charge, such as encouraging participation in programs that provide ongoing support. Payers can continue to advance the alignment of benefit designs to support diagnosis and treatment and incent participation in programs that achieve results. And finally, each individual must do their part to get help and help others before the already out of hand problem of obesity collapses our health care system and the economic viability of our country.

Interesting Information on the Survival Advantage from Having the Metabolic Syndrome

Check out this interesting article in JAMA by Jesse Roth about the genetic link between being fat and simultaneously being protected against tuberculosis (TB). Since readers may not have a subscription to JAMA, the Disease Management Care Blog is pleased to provide this Cliffsnotes summary about a disorder that we still have much to learn about.

One of the issues with obesity has been its link to the 'metabolic syndrome,' which is typically accompanied by increased 'background' inflammation. Experts have suspected that this in turn leads to chronic molecular 'wear and tear' that subsequently leads to chronic diseases such as diabetes, atherosclerosis and cancer. While the ability to preserve energy and store fat makes evolutionary sense for humans that have been at risk for famine, scientists have been mystified by the accompanying genetic programing that leads to ongoing cellular damage. Why would having a turbocharged immune system offer a survival benefit?

The answer may be the scourge of TB. Until antibiotics came along, this was an infection that, once established, could never be cured and frequently led to death. It's been estimated that TB has caused more than a billion deaths in the course of human history. For who survived, victims harbored the disease in a subacute or latent form for the rest of their lives. Having increased amounts of visceral fat leading to elevated levels of adipokines, tumor necrosis factor and other pro-inflammatory proteins may have given big bellied people a chance to beat or at least combat the infection.

It was long observed that persons with poor nutritional status seemed to be more prone to TB and were more likely to die from the disease. That's because starvation generally impairs immunity to the point where more persons succumb from just about any infection than from the weight loss itself. In contrast, persons with excess weight have heightened immunity with inflammation. While the link between the two conditions is still being unraveled, Dr. Roth speculates overweight allowed individuals to have the kind of heightened immune response that made them more likely to survive an encounter with TB. As a result, big people had a survival advantage.

Interestingly, high amounts of LDL are also involved in the immune response. Little wonder, then, that physicians in the pre-antibiotic era prescribed sedentary behavior in their sanatoriums with high calorie diets.

Individuals of Indian or Japanese heritage appear to develop the metabolic syndrome at lower levels of obesity. The Inuits, on the other hand, have historically low rates of obesity and seem to be especially prone to TB. This suggests the genetic trigger for inflammation may vary from gene pool to gene pool. These observations are leading scientists to look for the genetic and metabolic triggers for the inflammation that may be modifiable with yet-to-be-discovered medications.

Now that TB is largely absent in the U.S. and much of the West, the metabolic advantage that served us so well for tens of thousands of years is causing chronic illness.

A Tale of Two Diabetics

Meet Homer. His appetite for doughnuts and aluminum wrapped carbonated carbohydrate-rich beverages has finally caught up with him. His doctor has told him that he's overweight and has diabetes mellitus. An oaf he may be, but he’s a lovable well-meaning oaf who does his best to follow his doctor’s advice most of the time. He’s been told by his doctor about the role of diet, exercise, medications and regular follow-up. He remembers little of it.

Homer’s neighbor Ned hasn’t been immune from exposure to Fatland either. A victim of one too many yummylicious Church suppers, his waist line has also reached critical mass. He is very attentaroonie to the need for blood glucose control, has bought a meter and is already thinking of giving that eye professional he saw just last month a call to see if there was any sign of a new word he learned on line i.e., ‘retinopathy.’ He’s been told by his doctor about the role of diet, exercise, medications and regular follow-up. He’s tried to remember what he’s been told. He remembers little of it.

Who is going to have the better outcome – Ned or Homer?

While Ned is the obvious choice, don’t dismiss Homer, especially if he gets the kind of health care coaching that is tailored to his life-style preferences. While it’s always hard to predict just how Homer will process things, given his preferences, he’d probably be reluctant be hassled by the polypharmacy combination of medicines of dubious value and heightened risk of side effects that only marginally lower his A1c to that one-size-fits-all guideline value of 7.0% or lower. While he’ll probably neglect getting his yearly eye examination, chances are likely that his vision will do just fine. Because he works at a nuclear power plant, Mr. Burns – not out of any soft hearted notions of niceness but out of a hard assessment of a likely return on investment - has probably invested in an aggressive on-site wellness program that has made donuts far less available. Last but not least, Homer is high risk and has been tagged by a disease management organization as someone that warrants regular phone calls. Homer’s nurse has determined that Marge can be a resource in modifying Homer’s dietary habits.

By-the-book Ned, in the meantime, is probably going to go along with the ADA recommendation that he get his A1c below 7%, even if he has to take a combination of three different medicines to do it. While he’s worrying about all those side effects, the increase in his visits to the doctor is going to prompt additional testing and referrals for other long dormant conditions, including that vague pain he’s had in his low back and his concern that that long standing mole could be something serious. And by the way, Ned’s business pays for a bare bones health insurance program with a high deductable and no disease management support. There are no on site wellness programs and Ned doesn’t have access to any disease management.

The DMCB will put it's money on Homer.

Demystifying U.S. Health Care Spending--Some Surprising Information

Paul Ginsburg, of the Center for Studying Health System Change, has just authored a new report, "High and Rising Health Care Costs: Demystifying U.S. Health Care Spending." The report is part of the Robert Wood Johnson Foundation's Synthesis Project.This paper reviews existing literature in search of a more clear understanding of U.S. health care costs, the drivers, and the trends.It is an

Obesity: The Emerging Role of Disease Management and An Important Opinion Piece in JAMA

Good news. The DMAA has established an Obesity Resource Center. There are links to useful consumer information, links to a literature search engine preloaded with the term obesity, links to information that employers would find useful and other goodies.

There is also a link to the newly released DMAA Obesity Toolkit. The Disease Management Care Blog would like to immodestly point out that it was involved in its formulation. In it's humble opinion, the .xls spreadsheet that allows insurers to load assumptions into an actuarially sound calculator is a neat tool. Depending on what is covered, how it's paid for and what utilization patterns are likely, users can price the insurance cost of covering obesity-related services in a benefit rider. Very cool.

And while we're on the weighty topic of obesity, the Oct 15 issue of JAMA has come out with a provocative article on the food industry's inability to curb its insatiable appetite for profits. The authors, Drs. David Ludwig and Marion Nestle, describe a glutinous pattern of underhanded public relations that is designed to deflect criticism over the avarcious marketing aimed at getting consumers to eat more high profit-margin, calorie-dense, processed and waist expanding food.

The authors note that cars are responsible for a certain frequency of injury and premature death, yet we don't expect car manufacturers to regulate their own industry. Instead, the government uses a blend of regulations, taxes, mandates, incentives and the threat of being hauled up before a Committee of Congress to shape the industry. The FTC, U.S. Department of Agriculture, and the FDA have the means to deliver many of these readily available tools. Given the conflict of interest between maximizing shareholder value versus the public health burden of obesity, the authors call for these government organs plus academia and public health advocates to rigorously apply the appropriate checks and balances.

While the DMCB wishes the authors had mentioned the role of disease management organizations along with academia and public health, it will forgive them. It is also generally suspicious of government's ability to intelligently regulate, but it recognizes that the authors make a good point.

The DMCB thinks it would be neat if this article were posted on the DMAA Obesity Resource Center. It's.... good food for thought.

Pursuing Weight Loss Among Obese Asthma Sufferers: Time for Disease Management Organizations to Step Up

Most physicians are well aware of the association between obesity and asthma. While persons with obesity may complain of shortness of breath or have altered lung function because of their anatomy, it's been clear for a long time that there's more to the story. Genes promoting both may occur together, leading to a disposition to develop both diseases. Obesity provokes a systemic "inflammatory" state which may involve the airways leading to bronchospasm. Increased levels of leptin may also lower the threshold for airways to become reactive. Dietary factors may be responsible for both the increase in asthma incidence as well as the development of obesity. Persons with obesity tend to be more prone to gastroesophageal reflux, which can also provoke airway irritation and asthma.

Just because there is an association, however, doesn't necessarily mean one causes the other. Yet, that just may be the case here. Obesity tends to predate the development of asthma and there have been reports that reductions in body weight tend to lead to a reduction in asthma severity. Obesity may be guilty as charged.

The likely causal link and the benefit from weight loss should be of great interest to disease management organizations. They're probably on the phone right now asking thousands of enrollees if they are using their peak flow meters, if they have access to a rescue plan and if they are being compliant with their inhalers. The association of obesity and asthma, however, probably hasn't been enough for the DMOs to start asking about their asthma enrollees' BMI and, if obesity is present, readiness to enter a weight loss program.

Well, maybe after reading this article by Eneli and colleagues, it may be time to pursue obesity as a modifiable risk factor in asthma care management and start asking patients about weight. Eneli et al performed a literature review and found there are 15 studies on the topic and all have shown an improvement in at least one asthma outcome measure when there was obesity-reducing weight loss.

The Disease Management Care Blog recognizes that purists would argue that a prospective randomized clinical trial comparing weight loss to no weight loss among asthma sufferers is necessary first, preferably using an outcome of interest (for example, emergency room utilization) to the DMOs. Others may wish to wait until organizations such as the NQF or the NCQA get around to establishing weight loss among persons with asthma one of their measures. Or maybe they're hoping that the managed care organizations they contract with don't bring it up.

The DMCB disagrees. The causal link between obesity and asthma makes too much sense to wait. Asking height and weight among persons with asthma is a start (if medical records are not readily available). If the BMI is elevated, an assessment of readiness to change lifestyle may be warranted. If the patient is ready, DMOs have programs available that can help, or the physician can be alerted, or the patient can be referred.

Obesity, Increased Risk and Decreased Risk of Disease

Obesity is associated with hypertension, osteoarthritis, high cholesterol, diabetes mellitus, heart attacks, stroke, gallbladder disease, sleep apnea, uterine or breast or kidney or colon cancer, liver disease, infertility, birth defects, carpal tunnel syndrome, venous insufficiency, deep vein thrombosis, poor wound healing, gout, kidney stones, gastroesophageal reflux, psoriasis, dementia, rhinoliquorrhea (what ever THAT is), atrial fibrillation, asthma and big butts.

But (no pun intended) you knew that already. Can you name two conditions for which obesity may LOWER the risk? Answers here and here.

Extra credit: name a cancer for which tobacco use may lower the risk. Answer here.

Overweight, Obesity & Fitness: And Now for a Different Interpretation

The Disease Management Care Blog did not watch all of Reverend Wright’s sermons, because it preferred to take the time to read the original Archives paper on the interaction of obesity and exercise for heart disease risk in women. The DCMB suspects the Reverend would agree with the need to go past the dour headlines, which suggest overweight/obese women are doomed even if they work to remain active and fit. Intrigued by another possible example of the mainstream media once again being mistaken, unbalanced and muddled when it comes to journal reports, the DMCB thanked the Archives of Internal Medicine for keeping the manuscript accessible and waded in.

Based on data from the Women’s Health Study (WHS), Weinstein and colleagues used ‘hazard ratios’ to examine the impact of weight and exercise on the occurrence of heart disease over an average 11 years of follow-up. Hazard ratios are a tool that approximates ‘relative risk,’ which compares risk against a baseline rate. A ratio of ‘2’ implies the risk is doubled. In this instance, the baseline comparator was made up of non-overweight active women.

Over 38,000 women were followed and just under a 1000 were known to have developed a heart attack, need heart surgery or other procedure or have a stroke. Other concurrent conditions, like high blood pressure and diabetes were statistically accounted for/'neutralized.'

While being overweight (a BMI between 25 and 29.99) and inactive increased the hazard ratio (risk) by about 1.9 (i.e., almost doubled compared to being thin and active), being overweight and active had a hazard ratio that was less at 1.5 (the risk increased by 50%). Being obese (a BMI of 30 or greater) and inactive had a hazard ratio of 2.5, which decreased to 1.9 when women were active. Never mind the thin/active comparator. For both categories of overweight and obesity, going from active from inactive appeared to decrease the risk of heart attack, heart surgery and stroke by about 20% (and for the methodologists out there, that’s assuming there are no confounding variables and that the association is causal - and BTW that the differences are statistically significant).

But wait - it gets better. The authors described physical activity not in terms of formal ‘exercise’ but in terms of time spent walking; it appeared 30 minutes a day conferred protection.

So, based on this study, doctors, disease management programs, health educators, registered dietitians and other professionals can tell their women patients who are struggling with weight to be of good cheer: relatively modest levels of exercise are associated with a 20% improvement in the risk versus being inactive. The bad news is that overweight and obese women can’t exercise their way down the same level of cardiovascular risk as a thin active woman.

But it’s not even that bad. Note the data above were casted in terms of hazard ratios. A better question is what is the absolute risk? It’s not apparent in the Archives article above, but the DCMB had little trouble finding the answer in data from the Framingham Study. Having a BMI from 25 to 29.9 has a total yearly cardiac risk of 1.9 per thousand per year in women, while the risk among the obese is 2.4 per thousand per year. In other words the risks are 0.19% and 0.24% per year. The DMCB suspects that while being overweight/obese can ’double’ the risk versus thin persons, that doubling is at the margins. In other words, obese and overweight women have a 99% chance of NOT having a cardiovascular problem from year to year - with or without exercising.

This study is better thought of in these terms: if you are a woman with a high BMI, your less than 1% per year risk of heart attack and stroke may be decreased by a fifth if you walk 30 minutes a day. Doesn’t that sound better?

And finally, if you took the time to read that preceding 1000 word soliloquy-post on 'risk versus retail' (I apologize to readers about that, the DMCB got carried away), the above obesity numbers might lend some insight on why health insurers have been reluctant to include obesity programs as a covered benefit. Absent diabetes or heart disease (where the risk is considerable and weight loss can make a big difference in chronic disease control), obesity alone is probably not a big source of risk for the underwriters. They probably believe reducing the prevalence of obesity is unlikely to make a big difference in claims expense. Better to let it go retail.

Post script: we in the U.S. are not alone.

Post post script: slightly off topic, but while the DMCB agrees obesity is leading to epidemic levels of diabetes, hypertension and heart disease, it recalls seeing many otherwise well if chunky patients who were seeking 'treatment' because of how their girth appeared. Maybe the anti-fat bias activists have a point: our perception of health (as well as beauty) is also becoming distorted.

Obesity and Smoking--One Step Forward and Two Steps Back

Young Americans risk being the first generation whose health status will be worse off then the last.I have repeated that prediction many times but today it looks like tomorrow is here.A study by the Harvard School of Public Health and the University of Washington and published in the journal PLoS Medicine now tells us that the overall of life expectancy of many Americans has actually been in

The Disease Management Care Blog Dishes Up Some Straight Dope on Obesity, Heart Disease & Rimonabant

The Disease Management Care Blog thinks the Vytorin food fight from the 2008 American College of Cardiology meeting is not only overdone but it’s obscuring other news, such as this tasty morsel on rimonabant. This is a promising weight loss drug that blocks “cannabinoid” receptors. If that term sounds familiar, it should. There is another well known drug that shares the philology but stimulates the cannabinoid receptors; this accounts for its appetite-provoking “munchies” side effect. Because rimonabant blocks those receptors, it leads to a decrease in appetite. Rimonabant is manufactured by sanofi-aventis and is available in Europe. Not so in the U.S: after one unsuccessful attempt at getting it approved, the U.S. Food and Drug Administration sent it back because concerns about side effects. More on that later.

So that readers of the DMCB don't have to read the entire article, the rimonabant study summary is served up over the next 4 paragraphs. The DMCB then weighs in with some additional opinions. Tie on a bib and read on…..

This study was cooked up to determine if the appetite blocking effects of rimonabant was not only enough to lead to weight loss but to treat coronary artery disease. The study was done in classic state of the art fashion: volunteers across multiple clinics agreed to be randomly assigned one of two menu options: the drug rimonabant or an identical placebo.

And what were the ingredients? Volunteers had to have heart symptoms severe enough to warrant a cardiac catheterization. Other criteria included having a partial 20% or more blockage of at least one artery during that catheterization, a waist circumference of either 34.6 or 40.2 inches for women or men, respectively and to either a) have the “metabolic syndrome” or b) use tobacco. If those criteria were met, the study arranged for an ultrasound device to be placed into a coronary artery once the regular cardiac catheterization was finished. It was used to take sequential ultrasound pictures of the artery as it was slowly pulled out. The extent and thickness of the atherosclerosis, otherwise known as plaque, of the artery was measured. The volunteers were then randomized to drug or placebo. All saw a dietician at least once and were also expected to use local options for other weight loss. They were then let to age in a “blinded” fashion over approximately 18 months.

That’s when another ultrasound was ordered up. The measure used was the average “percent atheroma volume.” This is the amount of cross sectional area occupied by plaque versus normal artery. Atherosclerosis is a progressive disease, so the increase in percent atheroma volume should be greater in persons on placebo compared to the rimonabant users. That turned out to be the case, but the difference was not enough to be statistically significant; it could have happened as a result of random variation. For those of you with a taste for the actual the numbers, it was a 0.25% increase vs. a 0.51% increase, while the likelihood that random variation accounted for the difference was 22%.

The authors baked in other measures of plaque and found 3 dimensional “total volume” of the plaque was less at 18 months among the rimonabant users. This turned out to be statistically significant. However, there was no difference in heart attack, stroke, hospitalizations or death rates between the two groups. Rimonabant users lost just under 10 lbs and about 4 ½ inches of waist versus about a pound and 1 inch for the placebo users. This came at a price, though: 43.4% of the rimonabant users had a psychiatric issue come up during the study versus 28.4% in the placebo patients. Most of the issues were anxiety and depression. Suicide was rare: one person in the placebo group attempted it and one person in the rimonabant group succeeded.

So what can the Disease Management Care Blog bring to the table in thinking about this?

“Percent atheroma volume” (PAV) as a measure may taste great but it isn’t filling.

a) It’s a short-term or “surrogate” measure for the severity of heart disease. If the study had been carried out longer with more volunteers, the frequency of heart attacks themselves could have been better studied and we might have a good understanding of how rimonabant really performs. Studies like this are underway, so stay tuned.
b) While PAV predicts problems in the future, that predictive performance is best correlated with statin treatment for cholesterol, not calorie restriction treatment for weight. See a) above
c) Heart attacks seem to be a function of plague rupture more than plaque thickness. Even if rimonabant resulted in thinner plaques, that doesn’t necessary mean users will be better served by living longer. See a) above.

Secondly, rimonabant was not ala carte. It was accompanied by a helping of dietary counseling and follow-up. If this drug ever is approved by the FDA, the DMCB hopes that its use will be linked to meaningful dietary and activity coaching. Assuming such counseling is eventually “covered” by insurers at the prevailing fee schedules for similar evaluation and management (E&M) services, the DMCB will be very surprised if many physicians will want to fill their appointments with calorie counting and activity logs. They could hire a nurse or a dietician to do it, but it remains to be seen if the E&M revenue exceeds that cost. Rather, this sounds like a job for scalable “industrial strength” obesity (which may be a disease) management programs tailored by a menu of personalized care options.

The incidence of side effects gave the DMCB dyspepsia. Egads, there was a greater than 40% rate of psychiatric illness, probably from blockade of the “mellow” receptors. The FDA declined to approve rimonabant the first time because of reports of adverse mood changes and this report will likely not satiate their appetite for a better margin of patient safety. Since these patients may need mental health monitoring, the DMCB wonders if disease management can also fill that void - and appease the FDA.

To wrap things up: looks like rimonabant’s weight loss doesn’t necessarily benefit obese persons with heart blockages. However, that benefit was measured using a dubious surrogate measure. Whatever benefit may exist is linked to the type of care that can be provided by disease management. Given the 40% psychiatric illness rate, the advantages and disadvantages will need to be carefully assessed on a patient-by-patient basis and close follow-up may be warranted, perhaps also by disease management companies.

Obesity & Disease Management: Why the Industry is Happy to Fill a Vacuum

So just what is going on with obesity and disease management?

While persons with obesity have greater claims expense, insurers and the actuaries that advise them are unsure if programs aimed at reducing the severity and prevalence of obesity in a covered population truly result in savings. Accordingly, they fear that if they cover obesity treatment, medical costs will not only remain high, they’ll have to bear the cost of a richer benefit.

Health insurers' customers don’t want to hear that. CEOs and human resource leaders have looked at their insurance premiums and the body habitus of the employees in their cafeterias, assembly lines and cubicles and have concluded that there is a causal relationship between obesity and the rising cost of health care. They have decided that addressing the former will mitigate the latter. They also believe that preventive and conservative obesity treatment programs will reduce the looming and unaffordable cost of bariatric surgery.

They don’t find much comfort in the argument that expensive up-front coverage of bariatric surgery will ultimately result in cost savings in the long run. They would rather avoid having to choose between the up versus downstream costs of obesity. Many employers have also not given up on the belief that their human capital is worth the investment in high value, cost effective and preventive health insurance. One market judgment beats five evidence-based medicines. It also beats five actuaries.

Whether they like it or not, health insurers are under pressure to do something. For employers who are self insured, they’re also prepared to do something.

And how has the traditional health care system responded? Except for a few successes, the silence has been deafening. While physicians can use a wide range of diagnosis codes (making the DMCB doubt the contention that obesity treatment is not “paid for”), their training and the traditional one-on-one care approach to care has been ill-equipped to provide lifestyle counseling. It has also been simply out-numbered by the sheer volume of persons with obesity. Other resources, such as registered dieticians or nutritionists, are too few or hospital-based.

In the meantime, obesity has long been addressed as a co-morbidity by disease management programs; contrary to popular opinion, it’s been years since they confined their care protocols to single disease treatment. They have been including weight management as part of their approach to chronic illness for years. Given their pre-existing treatment protocols, infrastructure and willingness to sell population based approaches for any condition at the right price, they have been more than willing to fill the vacuum created by the growing prevalence of obesity, the demand for affordable treatment as well as the inertia of the traditional health care system. They have been more than happy to respond to the “do something” described above.

The disease management care blog is unaware of any studies that describe the number of persons in or the revenue from commercial disease management obesity programs, but it suspects the numbers are considerable. Surprised? Don’t be, because they have an understandable product at a reasonable price that promises an alternative to hidebound traditional medical care, high cost pharmaceuticals and even higher cost bariatric surgery.

Oh, and last but not least, it’s ironic that weight loss medications and bariatric surgery are most effective if they are paired with ongoing counseling and follow-up. Care to guess if the disease management industry is ready to get paid for this too?

More Background Facts on Obesity.

Yesterday’s posting on obesity prompted the Disease Management Care Blog to take a stroll through the obesity information market. The following factoids made it into the DMCB posting check-out basket. Here you are, in the order in which I pulled them out of the bags when I got home:

Here’s a good book on how U.S became one of the fattest nations in the history of the planet. Check out the economics behind high fructose corn syrup, cheap palm oil, supersized value meals and the demise of school based physical education.

And speaking of economics, it really does cost more to eat healthy.

According to Business Week, the estimate of U.S. obesity prevalence can be thought of as thirds: one third are obese, one third are overweight and one third are normal. Among the obese there is a category with a BMI of 40 or greater known as the extreme obese. This group comprises approximately 5% of the U.S. population. The 2/3 of the U.S that are overweight or obese represents a huge potential market for weight loss drugs, and the race is on to be the first to market with one that is safe and effective.

This report used NHANES data to show that medical expenses in the United States for being overweight (BMI 25–29.9) and obese (BMI greater than 30) added up to $92.6 billion in 2002. Prescription drugs currently are only $200 million.

There is a difference between “central” (where fat storage predominates in the abdomen) and “peripheral” (where fat storage is subcutaneous, often resulting in what has been described as a “pear look”) adiposity. Abdominal obesity is associated with a higher rate of disease burden, which may make measuring waist circumference a better disease-preventing screening tool.

The initial goal of weight loss therapy should be to reduce body weight by approximately 10 percent from baseline.

Bariatric surgery is a growth industry thanks to a 400% increase from 1997 to 2002. And yet, as of 2002, only 0.6 percent of the 11.5 million eligible persons had bariatric surgery. Partly to promote excellence, partly to protect market share and partly to preempt the creation of managed care networks, bariatric surgery centers can achieve status as centers of excellence.

For the managed care perspective on bariatric surgery, see this link. It comes down to safety and cost, in that order.

Unable to find much good news here, the DMCB is thinking of starting an 501(c)(3) advocacy group, named along the lines of “We Battle Obesity – So Are You.” We pledge to only accept pharmaceutical company sponsorship if its weight loss drug has an acceptable mortality rate. We will accept Bariatric Center of Excellence sponsorship if they agree to remit a portion of their surgical fee to the hapless primary care physicians that are supposed to provide follow-up for all these patients.

The DMCB anticipates a zero budget for the foreseeable future. I'll use some of that budget to review the implications for the disease management industry in an upcoming post.

JAMA Article about Obesity Disease Management

The publication of the Weight Loss Maintenance (WLM) trial in JAMA caught the attention of the Disease Management Care Blog. It’s one thing for patients to achieve weight loss. It’s another for that weight loss to be maintained.

The WLM trial is worth a close read because it a) rigorously tested state-of-the-art weight maintenance approaches that are typically used in disease management programs and b) provided an usually long period of follow-up.

The full study is available on line here. As a service to readers of the DMCB, I've provided a summary. To skip forward to lessons for the disease management community, scroll down to the bold text below.

In order to qualify for inclusion, persons had to have a BMI between 25 and 45 and have either high blood pressure or high blood cholesterol (heart disease and diabetes patients were excluded). Participants then went through 6 months of weekly group sessions consisting of diet (‘Approaches to Stop Hypertension’) and exercise advice. Persons who had lost at least 4 kilograms (about 9 lbs.) were then randomly assigned to one of three types of weight maintenance follow-up over 30 months: 1) personal contact (monthly 10-15 minute phone calls), 2) interactive technology (consisting of a personalized password protected web site) or self-directed care (some printed materials and goodbye). The study centers were Duke, Johns Hopkins, Pennington Biomedical Research Center and Kaiser Permanente.

The average starting BMI in the study participants was a generous 34.1. 1685 persons started the trial and 1032 (61%) managed to lose the approximately 9 or more lbs to qualify for the rest of study. The average weight loss was over those 6 months was 8.5 kg (18.7 lbs).

Over the 30 months of the study, the persons assigned to the personal contact did better than the web site or self care. Weight regain was 5.5 kg. (12 lbs) in the self directed group, 5.2 kg. (11.4 lbs) in the web-based group and 4 kg. (9 lbs) in the personal contact group. In other words, the personal contact patients avoided an average of 3.3 lbs weight gain. 42% in the personal contact group vs. 35% and 34% in the web site and self directed groups respectively stayed at least 5% below the entry weight. The impact on the programs on blood pressure and blood cholesterol went unreported.

Kudos to the authors for gauging the success of this program among a group of persons with special health care needs: African Americans. The subgroup analysis for these individuals revealed their program results were no different.

What are the lessons for the disease management organizations that offer weight loss programs?

First off, this study could have been titled “A study on the value of two already widely used disease management strategies vs. usual care for sustaining weight loss.” The researchers in this study saluted themselves for establishing the value of an “efficient and practical mode of delivery” but failed to mention that the personal contact phone call is in already place and available to millions of commercially insured persons who have access to disease management programs.

Personalized phone calls appear to work better than web-based interventions. I tried to get into the WLS web site to take it for a test drive but was unable to do so. It may or may not be as “rich” as commercially based programs’ web sites, which are constantly being updated and modified. Nonetheless, this is consistent with what disease management programs have known all along: high touch beats high tech. In other words, purchasers of disease management programs aka weight loss/maintenance programs get what they pay for.

Since the industry is constantly improving their web-based approaches to patient care, it’s hard to know if all commercially available web-based approaches to weight loss maintenance can be painted with the same WLS brush. In the estimation of the DMCB, that misses the point. In any population, there are persons who prefer web-based approaches. Persons with such a preference may be very successful in maintaining weight loss. That was not evaluated in this study. In addition, both web-based approaches and telephoney probably work better than either alone.

The disease management industry has a useful benchmark. Personalized weight maintenance follow-up can be expected to result in keeping about 10 lbs off among persons who initially lose 20 lbs.

National guidelines on the topic of weight loss recommend that one measure of the success of weight loss among persons with obesity is 10% of body weight. Using that very hard-to-reach threshold, this study was a complete failure. It’s depressing isn’t it? After all that time and trouble and state of the art treatment, persons with a BMI in the 30s lost about 10 lbs over the 2-3 years of the study. Reality check!

Last but not least, it appears that physicians were not involved. This may strike some as a threat to the profession, but a) physicians are typically not well trained in ongoing counseling for weight loss maintenance and b) the DMCB doesn’t think most primary care physicians are very interested in that kind of work anyway. That being said, it’s notable that the authors failed to note that one stumbling block to this “efficient and practical mode of delivery” may be a lack of physician buy-in in many usual care settings. The disease management industry knows this very well, but probably finds it ironic that this study was published in this journal named for the parent organization: the American Medical Association.

Lifetime Health Care Costs For the Obese and Smokers Lower Because They're Dead Sooner

This was the impressive conclusion of a study published by the Public Library of Science Medicine. The study was sponsored by the Dutch Ministry of Health Welfare and Sport.Obese people had the highest health care costs between the ages of 20 and 56. Obese folks and smokers were found to have a higher rate of heart disease than others.However, the authors found that the obese and those who smoke