Close Concerns Weblog

Employees and insurers see financial loss with weight-loss surgery

As diabetes has reached extreme levels in the US, the Center for Medicare and Medicaid Services (CMS) is looking closely at findings that suggest that bariatric surgery can dramatically improve glycemic control and can even in some cases cure diabetes by causes significant weight loss. In a recent study that was published in the January 23, 2008 Journal of the American Medical Association, 73% of people with recently diagnosed type 2 diabetes saw their diabetes go into remission after the surgery was performed.

Recognizing that bariatric surgery is more than a cosmetic operation, CMS is now considering reimbursement plans for obese people with type 2 diabetes who are not currently eligible for the surgery. Currently, the surgeries are reimbursed in people who have BMIs above 40, which indicates severe obesity. Those that have a BMI of 35-39 as well as a related illness like diabetes, hypertension, or cardiovascular disease are also usually covered for the procedure, which can cost anywhere from $15,000 to $35,000.

Medicare is now looking to cover diabetes patients with lower BMIs with the hopes that it will lead to
future savings in treatments. Before lower BMIs can be reimbursed, we look for changes to the NIH guidelines for bariatric surgery; currently, guidelines suggest that bariatric surgery should only be used in people who have BMIs above 40, or a BMI of 35-39 with a related illness.

However, the government will have a difficult time convincing employers and insurers to cover weight-loss surgery in patients with type 2 diabetes. There is an estimated five to ten year wait for an employer to recover surgery costs, excluding any extra visits or emergency care treatments. Critics question whether the government should be pushing surgical procedures for weight loss towards people with lower BMIs instead of renewing and revitalizing much needed educational tools and programs to help all people, not just those who are clinically obese or overweight.

While there is some truth to these criticisms, they ignore the fact that physicians are supposed to take their patients through fairly rigorous education programs before going ahead to perform such a procedure. The education is not only limited to behavior modification pre- and post-surgery, but also entails in-depth discussion (and often trials) of alternatives. In our view, it’s more a question of providing patient’s with options from which to choose the most effective method to attain the elusive “good health” that America is struggling to hold on to.

Good weather's coming, dust off those walking shoes for a good cause

Ok so this is a quick heads up WAY in advance.  We just heard about another great cause worth supporting. The Obesity Action Coalition is co-organising a national obesity awareness walk to bring attention to the need for prevention and treatment of the obesity epidemic that is taking the US by storm.

This event will take place in Washington DC at the National Mall  - Monument Park on Tuesday, June 17th 2008 starting at 6:30pm. You can register by clicking here and registration is absolutely free.

Taranabant – Not a magic bullet

The data for Merck’s obesity drug taranabant is out, and the verdict is: There is no magic bullet for obesity. Taranabant belongs to the same drug class as rimonabant, which is marketed in Europe as Acomplia but has not been approved in the US. Both taranabant and rimonabant cause weight loss by blocking the cannabinoid receptor type 1 (CB1) receptors in the brain – the very receptors that are activated by marijuana. So, in a sense, these drugs do the opposite thing as marijuana. Whereas marijuana is known (theoretically) to cause the “munchies”, these drugs seem to block food craving. There are loads of people who would love to stop desiring food, but there is no “calorie-free lunch” (pun intended).

Take me out to the ballgame... or buffet?

CNN just run a piece about a mildly disturbing trend in spectator sports leagues such as the MLB, NHL, NBA and NASCAR. Say hello to “All-you-can-eat seats.” It sounds pretty nifty from a business perspective to charge customers a premium for tickets that eliminate the hassle of clambering over multiple knees to get to the unbelievable line at the concession stands. That’s the idea behind these “all-you-can-eat seats.”

Childhood Obesity – The Shape of Things to Come

Dr. David S. Ludwig, a well-known and very highly-regarded child obesity specialist from the Children's Hospital in Boston, wrote a sobering editorial entitled "Childhood Obesity – The Shape of Things to Come" that was recently published in the prestigious scientific journal The New England Journal of Medicine. In his editorial, Dr. Ludwig projects that obesity in children may shorten average life expectancy by two to five years by midcentury (~2050). We stopped short when we read that - whew.

Combination therapy: the future of obesity drugs?

Few dispute the need for better drugs to treat obesity. In the US and around the world, obesity rates are soaring, driving the prevalence of related conditions like diabetes, and lowering lifespan. Lifestyle modification is only moderately successful at reducing weight in most patients, and bariatric surgery, though highly successful at reducing weight, is highly invasive, has safety concerns, and is not recommended for any patients with a BMI under 40 or 35 with a comorbid condition. Drugs currently lie somewhere in between lifestyle modification and surgery with respect to efficacy and invasiveness. Potentially damaging side effects of currently approved drugs are worse than dieting alone, but better than bariatric surgery. Tolerability is also an issues with many weight loss drugs. As a number of obesity experts have said, the eventual goal for obesity drugs should be to have the effectiveness of bariatric surgery, with the safety of lifestyle intervention.

Obesity in America: Over-eating or under-exercising or ....?

Is the cause of obesity increased energy intake or decreased energy expenditure? This question was hotly debated at the Cleveland Clinic Obesity Summit 2007 in late September. At the meeting, keynote speaker Dr. Kessler (the former FDA commissioner) argued that supersizing of unhealthy food – “fat on sugar on salt on fat” as he put it – is the primary cause of the obesity epidemic in America. Portion sizes are on the rise, and the food industry has learned how to make fast food ever more palatable and addicting. Americans, he argues, essentially addicted to the fat, sugar and salt the food industry presents us with.

On the other hand, well-known and highly regarded obesity expert Dr. Stephen Blair argued instead that decreased energy expenditure is the major contributor to the obesity epidemic. He pointed out that there is no evidence that the average number of calories consumed per day has increased, but there is overwhelming evidence that we’re using technology to lazier than ever – escalators have replaced stairs, and we even use remote controls to make the sedentary activity of watching TV just a little more sedentary. It’s a shame that technology isn’t instead used to make us more active – for example, with cell phones, it is now possible to walk and talk, but most people drive and talk instead of walk and talk. (We actually walk and talk a lot at Close Concerns so we took exception to this!)

So who do you believe? Are we overeating or under-exercising? Probably the problem is a combination of both and it would be great bottom line to have more incentives.…

American dichotomies: Red states, Blue states... What's next? Fat States, Lean states?

Even at this point, it’s been years since obesity officially has became a hot topic and prevention become a watchword, rates of incidence continue to rise. NPR put together a terrific broadcast on this in late August and we are sad to say that we just got around to listening to it – had we listened earlier, we would have been raving earlier. The sad truth on the obesity front is that things just keep getting worse - since 2003 not one state has shown a decline in obesity rates. Colorado comes out as the leanest state (which it has for many years!) while nearly one-third of all adults in Mississippi are obese, making it the heaviest state in the nation.

Weighing in on Bariatric Surgery and the NEJM recent reports

Nearly 180,000 people underwent gastric-bypass operations in the US last year (the most common type of bariatric surgery in which the volume of the stomach is reduced). Patients and health care professionals are taking a new look at bariatric surgery (surgery used to treat morbid obesity) in light of two landmark studies published in the August 23rd New England Journal of Medicine (NEJM).

Obesity abounds, new maps out

there's a very good (or very disturbing, depending on your perspective) feature on Revolution Health today, about whether your state (they have US only) is fit or fat. Here's the link - these maps have been shown over the years at diabetes and obesity meetings where doctors gather and where we go to learn what they are learning.

http://www.revolutionhealth.com/healthy-living/weight-management/obesity-epidemic?ipc=B00162

The maps are divided into different shades, showing the states where less than 10% of the state is obese, between 10 and 15%, and so on. I always got depressed when another year went by and they'd have to add another color, because the percentage had gone up.

So Revolution Health does the maps better than anyone - you can slide between 1990 and 2006 and chart exactly what the country has done. It's mind blowing.

If you move the cursor to 1990 (a year that I remember vividly - it wasn't that long ago!), there's only one lone state that has over 15% of the population obese - and that was at a time when the national average was 11.6%. So 12% obese, that obviously doesn't sound great, right (obesity was defined as a BMI over 30 - yes there are problems using BMI as a definition, but still...)

So 1990, Mississippi (remember spelling that out as a kid?!) was 15%, and that was a green state. The only green state on the map - all the other states were gray (less than 10%) or, forebodingly, blue, which was between 10 and 15%. No states were yet yellow (20-24%), orange (25-30%), or red (over 30%). There were still at least 10 gray states then.

Flip to 1992 and there were just three gray states (Hawaii and Colorado - makes sense - and Arizona).

Flip to 1995 and there's a new color introduced, yellow, to signify 20-24% obese. One state is there, Indiana, with 20.1%.

Flip to 2000 and there's yet another new color introduced, orange, to show states with 25% or more obesity - and there, Mississippi again, 25%.

Move to 2001, 2002, 2003 ... and just more and more orange seeps into the graph. It's surreal. Meanwhile, Colorado is still blue, so below 15% obesity, oh good. Oh, no, actually, 2002, Colorado is green, so 15-19% obese.

Wow. 2005. ANOTHER new color, red, to show over 30% obese (30%!), and right away, the first year red hits, already there are three states. Which? Mississippi, right, at 30.9%, Louisiana at 30.8%, and West Virginia at 30.6%. Whew.

And then, today, the 2006 numbers are out. Overall, the obesity avarage has gone from 24.4% a year ago to 25.1% today. The map is so much more orange, allofasudden - in 1990 (which remember, I remember vividly and I'll bet you do too!), the obesity average was 11.6%. There are still three red states and still just

A word about green. In 2006, the only green is Colorado, but in 2004, there were at least five green states, among them Montana (19.7%), Massachusetts (18.4%), Connecticut (19.7%) and Vermont (18.7%) AND Colorado (16.8%) - but in 2006, there's just Colorado in green, though the obesity percentage there has increased to 18.2%. Stay green, Colorado! You can be the inspiration!

Here's one glimmer - obesity did according to these figures increase less from 2005 to 2006 (24.4% to 25.1%) than from 2004 to 2005 (23.2% to 24.4%). Is that because more people are out walking, paying attention to their hearts if nothing else? Mmm, I'm waking up our two year old and headed out now - this is all pretty frightening, especially for someone with diabetes.

So I am sort of morbidly fascinated with these graphs. It's 7:40 am and I feel I could play on it all morning. ...Exactly! That's the problem. Okay, I'm going to wake up Coco, get her her favorite soy milk in a sippy cup and walk with her to the Mission and get a coffee, sans the favorite Tartine morning bun ...if nothing else, the maps are inspiring me to turn it around and I hope I feel this way again tomorrow morning!