Economics and Reimbursement
1. Economics of Obesity
William H. Dietz, CDC Director of Division of Nutrition and Physical Activity
• Dr. Dietz provided an overview of “the economics of obesity,” offering some compelling statistics in support of funding interventions. For instance, he cited a recent statement by GM that obesity costs GM $1500 out of the price of each new car, and that they spend more on medical coverage for their population than they spend on steel to make new cars. The CMS has reported that 15% of the GDP is devoted to medical expenses, and USA Today projected that to increase to 19% of GDP by the year 2014. Increasingly these costs are being driven by chronic diseases, and these chronic diseases are being driven by obesity.
• In the face of all this spending, we are not necessarily spending our money wisely. A curve of life expectancy versus health care spending showed a flattening of the curve, indicating a clear drop in marginal utility for additional dollars spent. In Japan, half as much money is spent, but they have a much greater life expectancy. Investment in prevention may be cost beneficial.
• Increasingly, costs are being shifted to employees. According to Dr. Dietz, we are close to and perhaps already at the point where take-home wages are declining as a result of the increase in medical costs.
• 19% of cancers in women and 14% of cancers in men are attributable to obesity, and we are seeing increasing hospitalization for sleep apnea, diabetes, and other obesity-related conditions. The costs from obesity fall into five categories: illness, absence from work, reduced productivity, injuries, and disability. 75% of all injuries occur in people with BMIs > 25, and obese people are absent from work about twice as often as non-obese people.
• The current issue of the American Journal of Health Promotion analyzes per capita expenditures by BMI category. The investigators found that excess annual costs range from $162 for those with BMI of 25-30 in men to $1,524 for those with BMI of 40.0. For women, the same categories have costs of $474 and $1,302, respectively. We were surprised these weren’t higher.
• 25% of obese adults were overweight as children, and 50% of adults with a BMI >40 were overweight during childhood. Here again, we’re actually surprised this figures aren’t higher.
• Dr. Dietz argued that these excess costs provide a crude estimate of what we could spend to achieve reduction in these morbidities.
• Last week’s MMWR (Morbidity and Mortality Weekly Report) recommended combined nutrition and physical activity programs in work settings as a way to control weight. A major challenge, it appears, lies with handling small companies: companies with 5000+ employees are 32% of the workforce, whereas firms with <499 employees are 50% of the work force.
2. Economic Incentives and Obesity
Dr. Eric Finkelstein
• Dr. Finkelstein began with some economic perspective on why obesity is on the rise. Food is cheap and getting cheaper, and this is especially true for preprocessed foods. So-termed “accidental exercise,” or daily exercise that is not part of a planned workout routine, has dropped off dramatically.
• In an extremely interesting point, Dr. Finkelstein presented data about Americans’ knowledge of the risks of excess weight. In a phone survey that inquired about individuals’ risks for health problems and life expectancy, overweight individuals estimated higher relative risks. Obese individuals stated still higher relative risks, and the self-reported life expectancies were close to correct. Notably, obese adults forecasted life expectancies four years less than healthy weight adults.
• This study suggests that information-based interventions are likely to have limited impact. In contrast, obesity interventions that affect the costs and benefits of behaviors related to obesity are likely to be more effective. In other words, merely educating the public about the health risks is not going to lower rates of obesity. Like a true economist, Dr. Finkelstein argued for economic incentives in weight loss.
• The two areas from which programs are likely to come are the government and employers, as these two bear substantial costs for obesity. Approximately half the health care dollars attributable to obesity are paid by Medicare and Medicaid, and overweight and obesity expense costs the government $90 billion per year.
• Employers are more likely to get involved first, in Dr. Finkelstein’s view, and he advocated for incentive-based health promotion programs - for instance, subsidizing a gym membership or giving points or money for physical activity. He pointed out that the reality is that it costs money to lose weight, to join a gym and to buy the right food.
• According to Dr. Finkelstein, this strategy makes sense for employers, because it is low-risk: if no weight is lost, it costs the employer nothing, and lost weight saves the employer money.
3. “Metabolic Syndrome”
Dr. Steven Haffner
• This presentation was geared toward an academic audience, detailing the different definitions of metabolic syndrome as well as its clinical significance. Echoing what he highlighted at the sanofi-sponsored symposium, Dr. Haffner noted that while some of the agreement is over different conceptual frameworks, “people have pride and ownership,” and ego plays an important part in the debate.
• He divided the definitions into three different models:
o 1- Environmental causes: This describes the model advocated by NCEP and IDF, which says that environmental causes are responsible for the epidemic of the metabolic syndrome. It calls for a treatment based on the reduction of obesity and an increase in activity.
o 2- Insulin resistance: The WHO definition suggests that insulin resistance is the “underlying cause” of metabolic syndrome. In this definition, insulin resistance is a requirement for metabolic syndrome. The treatment in this case is to reduce obesity and increase activity and to use insulin sensitizers.
o 3- Inflammation: This is another concept not attached to any one organization. It posits that inflammation is the underlying cause of metabolic syndrome. In this case, the treatment is to reduce obesity and increase activity, as well as to use insulin sensitizers, statins, ACE inhibitors, and ARBs.
• One of the more fascinating aspects of Dr. Haffner’s presentation was his focus on motivation and understanding the origins of the definitions. For instance, NCEP is a lipid group, and two of their five criteria are lipid-based. Others might have suggested combining them into one category using an either/or listing.
• Dr. Haffner also noted that many companies latched onto the WHO definition because it was more “pharmacological friendly.” He used the term “market expansion” in referring to the criteria of insulin resistance, since this is a condition that describes not only people with type 2 diabetes, but also those with impaired glucose tolerance and impaired fasting glucose.
• The ATP III definition requires that a patient have three out of these five: abdominal obesity (high waist circumference), elevated triglycerides, low HDL-C, high blood pressure, fasting glucose above 100 (the cutoff was 110 in the original definition—Dr. Haffner again referred to “market expansion”).
• One of the principal critiques of the ADA has been that the cutpoints for each category are dichotomous and so lose important information.
• Another critique of the ADA definition is that not all risk factors contribute equally. Low HDL, blood pressure, and diabetes are the most important risk factors for CVD.
• Regarding obesity and metabolic syndrome in children: for those with a BMI of 33, the prevalence of metabolic syndrome was 39%; for those with a BMI of >40, the prevalence was 50%.
• Approaches to treating metabolic syndrome include behavioral therapy (weight loss and increased activity), the treatment of existing risk factors, and the use of insulin sensitizing therapies in nondiabetic subjects. This last approach is controversial, and when questioned on this point, Dr. Haffner said that in general he did not think that this should be done. He did think, however, that those with metabolic syndrome should be given an oral glucose tolerance test to check for impaired glucose tolerance and diabetes mellitus.
• We understand another new definition of metabolic syndrome may be in the works and could be presented soon.
4. The Role of the Intestinal Foregut in Diabetes Resolution and Appetite Control after Gastric Bypass Surgery
Francesco Rubino
• Dr. Rubino attempted to elucidate the hottest question regarding bariatric surgery, which is: what exactly is going on? As one internist told us yesterday, “as usual, the surgeons got the right answer with the wrong idea.” What began as an attempt to induce weight loss by reducing the size of the stomach has been found to have unbelievable metabolic impact. It seems that many of the gut hormones—ghrelin, CCK1, PPY,GLP-1, leptin, alpha-MSH, HOMA-IR, others—change dramatically after the surgery, generating much of the positive effect.
• In fact, the restricted stomach pouch is not a major factor in the weight loss seen after gastric bypass. In another surgery, gastric banding, there is restriction but no rerouting or short-circuiting in the stomach—and it is not nearly as effective.
• In gastric bypass, 95% of the stomach, the whole duodenum, and the first part of the jejunum are bypassed. The procedure is very effective, but there is little knowledge about the mechanism of action.
• Many experiments are being done in Zucker rats to try to understand what hormonal changes are important and how these are induced with the surgery. So far, the answer to the question is still very unclear.
• Perhaps the most astounding metabolic effect of gastric bypass is that patients with type 2 diabetes no longer have it after the surgery. This happens immediately, not progressively in conjunction with weight loss. Dr. Rubino stated that sometimes this happens before people leave the hospital. 83% of diabetic subjects have euglycemia up to 14 years later.
• Dr. Rubino approached the topic carefully, saying, “I don’t know if this is a cure, but if it’s not, it looks very close to that kind of concept.” This clearly raises the question: is type 2 diabetes an operable disease? He noted that asking this question might antagonize diabetologists, and he showed a photo of a small kitten (the surgeons) surrounded by a pack of Dobermans (the diabetologists). Dr. Rubino then walked through several experiments that bypassed different sections of the rat stomach.
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