State of the Art Obesity Management - Keep It Away from Primary Care

In the course of the Population Health Blog's last primary care encounter, a measurement of its height and weight determined that it was overweight.  On the way to the examination room, the nurse apologetically provided a patient education leaflet. The physician let the topic go unmentioned.

These health care professionals clearly were not "into" managing weight issues in their patient population.

After reading this paper, who can blame them?  A review of fifteen randomized clinical trials involving over 4500 patients showed that while primary care-based "behavior change for weight loss" results in statistically significant weight loss, the average amount was a clinically insignificant 3 lbs.

While web sites such as this provide useful pointers on engaging patients on the topic of weight loss, the U.S. Preventive Services Task Force (PSPSTF) recommends that persons with obesity be referred to a care setting that specializes in intensive multi-component behavioral interventions.

The primary care PHB agrees: these frontline clinics can screen for obesity using height and weight, but that's where their responsibility arguably ends.  Until there is research that shows otherwise, the primary care setting is no place for management of weight issues.

The PHB's care was state-of-the-art.

Is One DIet Program Better Than Another for Weight Loss?

As a doctor, the Population Health Blog was often asked by overnourished patients to help find a "best" diet.  Its advice to simply eat less and skip desert, however, was insufficient to overcome the commercial programs' allure of word-of-mouth, dubious advertising and fanciful on-line marketing . As a result, many desperate PHB patients fell into closed loops of pseudoscience, anecdotal testimonials and expertly crafted statements "not evaluated by the FDA."

As a population-health skeptic, the outcomes-focused PHB was never convinced that one commercial diet plan was "better" than any other.  Not only are excess calories very efficiently turned into corpulence by a very efficient human metabolism, it didn't make sense that that persons could eat their way to weight loss with more [insert one of the following: protein, fat, fiber, pre-packaged meals or vitamins].  Last but not least, if all these commercial weight loss outfits spent a tenth of their marketing budget on real science, the PHB may have had the evidence it needed to make a recommendation.

Well, a meta-analysis of "Named" (you'd recognize the brands) diet program outcomes has been published in JAMA and the results are decidedly unimpressive.  The good news is that all of the household-name programs result in modest weight loss compared to no diet.  The bad news is that the loss of two to six pounds for each program was no better or worse compared to the others.

The PHB's take?  It's up to the consumer to weigh their personal preferences for one type of diet plan vs. another.  In addition, out-of-pocket costs may also play a role in helping sustain the dieter's motivation in getting their money' worth. 

Beyond those two considerations, however, it's just a matter of eating less calories, not more of the latest nutritional fad.

Obesity Surgery in Diabetes Mellitus: A Three Year Trial Shows High "Cure Rates." The Implications for Population Health

In case there is any doubt about the long-term efficacy of obesity surgery for diabetes, check out this three year study that was just published by the New England Journal of Medicine. 150 persons between the ages of 20 and 60 years with an A1c greater than the recommended target of 7% and a BMI greater than 27 were randomly assigned to either gastric bypass, sleeve gastrectomy or intensive medical therapy. 8 persons dropped out after being assigned to medical therapy and one patient had their surgery cancelled. Over the next 3 years, 4 persons were lost to follow up.

Of the remaining participants, two thirds were women and three quarters were white. The mean age was 48 years, the average BMI was a prodigious 36 and the mean A1c was a poor 9.3%, with an average duration of diabetes of just over 8 years. 

Of the 40 medical patients, 5% ended up with an A1c of 6%, versus 38% of the 48 bypass and 24% of the 49 sleeve patients.  The average weight loss was 4.3 kg in the medical patients vs. 26 and 21 kg in the bypass and sleeve patients. While only 2% of medically treated patients were able to stop their diabetes medications, 69% and 43% of the bypass and sleeve patients were able to do so. Only four patients in the surgery groups required additional surgery for the treatment of complications.  None died.

The Population Health Blog finds the results compelling enough to believe that the surgical option for obesity-related diabetes mellitus may be turning out to be a first line option.  The complication rate is acceptably low and the "cure" rate of up to 70% (if defined as not having to take medications) is likely to be welcomed by patients facing a lifetime of otherwise chronic illness.

Criticisms?

Critics may worry that any long-term economic benefits at a population-based level may be cancelled by the cost of surgery.  The PHB understands that, but doesn't believe that obesity surgery should be viewed through a "return-on-investment" lens.  Rather, the value assessment of "outcome" (in terms of diabetes and obesity cure) per unit of cost (dollars spent) is a as good as an investment compared to, say, coronary artery bypass grafting or a knee replacement.

Critics may also worry that obesity surgery is more of a symptom of an overfed society and that our national treasure would be better spent on understanding our dietary dysfunctions.  The Population Health Blog cannot disagree, but doubts that our national health spending can be wired so that every dollar spent on the promotion of nutritional wisdom will reduce the near-term health care cost crisis from diabetes.  We need to be prepared to invest in both.

Implications for Population Health

It appears to the PHB that this was a single site "efficacy" study involving an academic medical center.  We don't know if the low complication rate observed here is typical of other hospitals that offer obesity surgery.  In addition, this study did not examine the impact of the more popular approach of banding surgery.  That being said, this three year trial suggests that bariatric surgery should be offered in the suite of options for persons meeting the criteria above.

The good news is that shared decision making has already been evaluated in this setting.  While the majority of participants are more likely to chose conservative treatment, the point is that a 40-70% chance of cure over three years should be raised in the course of patient-centric coaching.  Population health vendors in the diabetes-obesity "space" should be prepared to engage patients on this treatment option and help them decide if surgery is the right choice for them.

Image from Wikipedia

Time for Docs to Get Out of the Food Wars

In Food Fad Fantasyland, rotund patients can see their primary care physicians and discuss the merits of Atkins versus South Beach vs. [insert name here].  Armed with the latest nostrums, patients go forth and diet until the next twerk comes along.

Bleh.

While physicians and the for-profit care management vendors can disagree about many things, one thing they can agree on is the ability of their corpulent patients to swear by an endless number of diets.  Whether its "low carbs" or "Mediterranean" or "mini-fasts," docs and coaches alike are expected to not only endorse these fads, but deploy insider jargon like DMCB spawn watching the MTV Video Music Awards. Taylor Swift was crooning about... who?

Which is why, after reading this JAMA Viewpoint article, the Disease Management Care Blog agrees that it's time call a time-out.  It's also time for the DMCB primary care colleagues to exit.

The DMCB explains.

Drs. Pagoto and Appelhans point out that when it comes to weight loss and risk factor reduction, there is no research that convincingly proves that one dietary approach is superior to any other.  Outside of individual preference, the mix of nutrients makes no real difference.  Instead, say the authors, what's important is adherence.  In other words, once patients embark on their preferred diet, they have to stick to it.

Unfortunately, that message has been lost in the multi-billion dollar faddism that has come to dominate the food industry marketplace.

Skeptics will point out that getting persons to stick to a particular diet is a fool's errand.

Not so, say the JAMA authors. Pointing to the Finnish Diabetes Prevention Study, The Da Qing Diabetes Prevention Study and the Diabetes Prevention Program, they note that long-term behavior change that includes behavioral modification and lifestyle change is very possible. 

"Hear hear!" says the DMCB.

As most doctors are aware, most health insurers (including Medicare) don't really reimburse enough to meaningfully cover the true costs of life-style related counseling.  What's more, selective memory recall means that physicians generally remember just how often their counseling leads to their individual patients being as fat as ever.  Most of us physicians are not that good at coaching anyway.

Which is why the DMCB thinks dietary counseling should be outsourced outside of the doctors' offices.  The good news is that wellness and health promotion programs are becoming more adept at focusing on patients' adherence to lifestyle change, mostly by finding those with a willingness to change. It's then a matter supporting those individuals over the course of a year or more. 

This is just one example of the approach.  There are more to come.

The DMCB conclusion

1. Docs should be "agnostic" when it comes to one diet fad vs. another.  It's patient preference.  Next.

2. What really counts is adherence to long-term lifestyle change.  Since many physicians are not good at that kind of long-term coaching, better to let other programs offer their wares to insurers.  The key for these programs is to focus on lifestyle change for those patients who want it and can accomplish it.

Governor Christie's Weight and How CNN Got It Terribly Wrong

Good for you, Guv!

In the course of its medical career, the Disease Management Care Blog has encountered a plethora of, um, let's refer to them as overnourished patients.  When the DMCB broached the issue, it typically confirmed what the peer-reviewed literature has shown: a large majority already knew they were fat.

Unfortunately, the literature also suggests physicians could do a better job of increasing awareness and combating unrealistic "dream BMIs" with education about the benefit of a modest 5% weight loss in reducing the medical risks that come with Governor Christie-style big belly.

And speaking of the Guv.....

Almost 600 persons who follow the DMCB on Twitter already saw this typically contrarian and provocative tweet.....

Does N.J Gov Christie's #obesity ( http://politi.co/UXm4cT  ) doom him? "Attributable risk" may say odds are in his favor http://1.usa.gov/14RFeF6

... where it was pointed out that there is good science that shows that being big adds a significant but an absolutely small degree of mortality risk. 

In other words, the likelihood that an obese person is going to keel over in any given day is quite remote.

That inconvenient fact, however, didn't stop former White House Medical Unit Director and physician Connie Mariano from proclaiming lurid warnings to the TV watching public about Mr. Christie's looming mortality on CNN ("I'm worried about this man dying in office!"). 

Predictably, the Governor, already aware of his girth, pushed back. 

And who can blame him? While Mr. Christie obviously knows he's big, is in the public domain and hasn't been shy about discussing his size, he has a point. The lack of a doctor-patient relationship with Dr. Mariano means she doesn't have access to his full medical history.  Mr. Christie argues that, despite his weight, he's still relatively healthy, which is very possible.  As pointed out in the science-backed tweet above, the statistical likelihood - based on weight alone - that New Jersey's Chief Executive is going to die anytime soon is quite small.

Dr. Mariano's factual ignorance is one thing, but enabling the CNN's unwitting paternalistic stigmatizing ("attempted to give himself a clean bill of health") of obese Americans is another. While physician attention to fatness is important, there is no shortage of good physician guidelines on how to broach the topic, provide a supportive environment and offer helpful counseling. While the DMCB thankfully didn't detect any overt "fatsim" in the talking-head doctor's commentary, it's no secret that negative stereotyping among physicians is all too common.

While even White House physicians can be forgiven for their naivete, the DMCB thinks our national media should be more responsible.  To those patients who watch CNN and rely on it for information about obesity, the DMCB suggests you may want to use your remote and punish news outlets when they descend into spectacles like this. 

We deserve better.

Image from Wikipedia

Texting to Promote Weight Loss and in Population Health Management

Anyone who regularly attends a house of worship is certainly aware of how preachers make a point of regularly visiting parishioners while they're in a hospital. Since the Disease Management Care Blog's recent hospitalization involved an inconvenient distance (hour and a half drive) and time (6:30 AM), the DMCB pastor adapted by texting a prayer message. The DMCB took some comfort in what its colleagues euphemistically refer to as "faith healing."

Which is one reason why the DMCB paid attention to this interesting peer-reviewed abstract. 170 obese persons were randomly assigned to either monthly emails or daily "personally relevant and interactive" text messages. There was no difference in weight loss at 6 and 12 months of follow-up, but persons who were "adherent" to the text messages had statistically significant greater weight loss and greater activity levels.  Satisfaction levels were also high in the text message group.

And then there's this other study that randomly assigned obese college students to text messaging plus Facebook, Facebook alone and a "waiting list" control group.  In the limited follow-up of 8 weeks, the text messaging group lost a significantly greater amount of weight (2.4 kg.) vs. the other two groups.

Is texting an option for weight loss in particular and for population health management (PHM) in general?  These two studies would indicate the answer for both is "perhaps."  A better answer may be that texting plus other PHM interventions is better and that texting for persons who prefer it is best. 

The DMCB's Fat Lady might also approve of texting. If it's good enough for the prayerful among us, who can argue against it?

Image from Wikipedia

More on the Parallels Between the Sugary Beverage Ban and the Accountability Movement in Health Care

Time for some DMCB humble pie.

Check out Troeltsch's perspicacious response to the Disease Management Care Blog assertion in yesterday's posting that a New York City ban on the sale of 16 oz. calorie dense beverages would "work":

What evidence do you have for the comment "it works?" particularly in light of the fact that soda is simply banned in restaurants, and not any where else in the city?

Troeltsch has both right. 

The proposal, as it now stands, would limit the ban to restaurants, street vendors and concession stands and spares grocery stores. So while New Yorkers couldn't buy that "Big Gulp" to-go, they'd still be able to buy that liter of fructose corn syrup-loaded soda and continue their gluttonous ways in the privacy of their own homes.

And what's more, the DMCB did a literature search and can find no published evidence that a calorie-dense beverage ban reduces the prevalence of obesity. Yesterday's claim that "it works" was simply overzealous. DMCB readers can not only spot non-scientific puffery at meetings, in news reports and in marketing materials, but also in the DMCB's weaker-moment writings.

Well done.

That being said, the DMCB still gives the Big Apple some credit. If you go to the original proposal, you'll see that the ban is only one of 26 initiatives that seek to improve nutrition and increase exercise in the city's public schools, alter sidewalk and building codes to promote physical activity, require hospitals to offer healthy menus, increase the availability and appeal of tap water and promote wellness, especially among public employees. This is commercial population health management writ large.

And the DMCB still stands by its original assertions. Mayor Bloomberg's attack on obesity in the name of public health should remind health care providers that a similar fate awaits their costly ways if shared savings, accountability, bundling, electronic records, the demos and ACOs fail to bend the curve. Instead of trimming excess calories, our politicians will trim excess costs by proclamation.

The DMCB offers three additional observations:

1) Peter Orzag, one of Mr. Obama's health reform architects, famously asserted that the Affordable Care Act's health mandate provision would increase a collective expectation that we should all buy health insurance, much like seat belt laws prompted most of us to buckle up. There may be something to that in the anti-obesity fight, says the DMCB, and Mayor Bloomberg's very public attack on sugary drinks may prompt his city to shift to a new cultural norm

2) The DMCB hopes NYC's Department of Health and Mental Hygiene devotes the resources it takes to adequately measure the impact of the ban. The rest of the country needs to know if this works.

3) Last but not least, if nothing comes of this, this is one more warning to a largely uncooperative and unrepentant food industry.

Parallels Between the Sugary Beverage Ban and the Accountability Movement in Health Care

If New York City's Mayor Michael Bloomberg has his anti-obesity way, the Big Apple will begin banning the restaurant and concession sale of sugary beverages that exceed a volume 16 fluid ounces as early as March of 2013.  The Disease Management Care Blog suspects there is one big reason why Hizonner is deploying brute force in this battle of the bulge, this confrontation of the calories, this attack on adiposity:

It works.

Contrast the approach of simply outlawing obesogenic drinks with kinder and gentler approaches, like those based on education (food labeling and warnings), economic incentives (fat taxes), appeals to self-interest ("you'll look and feel better!") or enculturation (starting with food choices in our schools' cafeterias).  They all have their role, but let's face it: we don't heed labels, hate taxes, find life-style changes difficult, are suckers for the food industry's marketing and ultimately like the taste rush of corn syrup.  Take a stroll through Manhattan and it's pretty obvious we have a problem.

The Big Apple is doing this for our own public health good.

This lesson prompts the Disease Management Care Blog to ponder the largest threat to the success of the "accountability" movement in health care.  By "aligning" economic interests, offering savings-based "gain-sharing," leveraging decision support and enculturating physicians into "systems" of care imbued with best practices championed by physician leadership, we believe our collective taste for high cost testing, technology and pharmaceuticals will fade faster than the flab on The Biggest Loser.

Is that so?  Maybe not, and so the DMCB offers up two observations:

1. Assuming physicians are people and patients have their self-interest at heart, the likelihood that our appetitite for over-testing, the latest tech and brand name drugs will be blunted by electronic health record decision-support warnings, the promise of some savings-based future bonus, appeals at staff meetings to do the right thing or an expectation that physician culture will change is about as realistic as a successful John Edwards White House run in 2016.

2. And assuming that none of that works, the likelihood that future local and national politicians will use the same public health logic and announce a Bloomberg-esque "ban" of some high cost low value tests, technology and drugs is almost certain.

You read it here first.

Image from Wikipedia   

Qnexa for Obesity: Should It Ever Be Prescribed Without Concurrent Lifestyle Counseling? The Role of Disease and Population Health Management

Physician waiting room chair
for Qnexa candidates?

It's that time of year again. A political as well as cinematic blur of uninspiring candidates are being manipulated by an opaque, unaccountable and moneyed white male nomenklatura that foists "winners" on an unsuspecting public. The Oscars, the primary election year.... what's the difference?

So the Disease Management Care Blog distracted itself by turning its bloggy eye to newsmaker "Qnexa." This is a combination of two well known appetite suppressant drugs, phentermine and topiramate, that was just reviewed by an FDA expert panel. Their 20-2 vote in favor of approval makes it likely the Qnexa will be released to the market for the treatment of obesity sometime after a final Agency review in April.  Investors in Vivus like what it means for the company's prospects.

Population health management service providers should also like the prospects.

That's because Qnexa hasn't been tested as a stand-alone drug and, based on the published evidence, there is no evidence that it works without concurrent lifestyle counseling: 

The CONQUER Trial: "...assessed the efficacy and safety of two doses of phentermine plus topiramate controlled-release combination as an adjunct to diet and lifestyle modification for weight loss and metabolic risk reduction in individuals who were overweight and obese, with two or more risk factors."

The EQUIP Trial: "All patients were provided with standardized lifestyle counseling."

The SEQUEL Study: "All subjects participated in a lifestyle-modification program."

As the DMCB understands it, the FDA expert panel has recommended that Qnexa's release be tied to careful monitoring for an approximate 5% absolute risk of heart valve abnormalities. The DMCB believes they got it half right.

Access to Qnexa, based on the evidence, should also be explicitly tied to concurrent lifestyle counseling.  Assuming physicians are still unable to incorporate this into their usual clinic work flows, that leaves pharmacy benefit managers (who have supported patients with diabetes), patient centered medical homes and, last but not least, disease and population health management vendors.

Image from Wikipedia

Weighing In On The Population-Based Lessons from The Biggest Loser

But for being born centuries
too early, another potential
TBL contestant!

Despite vowing to never let it happen again, the Disease Management Care Blog was ensnared, along with over 7 million viewers, into watching much of last night's NBC's The Biggest Loser finale.  While the participants' physical transformations were truly astonishing, it found the lachrymose blubbering, manufactured suspense, emotional vulnerability and emphasis on exercise over diet so awful, it couldn't look away.  The icing on this cupcake was $100K winner Jennifer's spooky mydriatic gazing "bedroom eyes." 'Nuff said about that.

The good news is that this media mugging didn't stop the DMCB from extracting three weighty insights.  To wit:

Focusing massive amounts of personalized counseling for persons who are simultaneously at high risk and exhibiting willingness to change is certainly part of the answer to managing the population-based dimensions of obesity. Alas, while that makes for good pseudodrama, the DMCB worries that the show is promoting a belief that all the obese really need is some gumption and a personal trainer.  The science says otherwise.

In thinking about the distribution of obesity among normal adults (a graph is here), The Biggest Loser is intensely case managing a small number of persons at the farthest right side of the curve.  Case management has a role, but the complete answer includes overlapping strategies that move the entire weight curve to the left with less sensational but proven evidence-based interventions. They include promotion of smart food choices, portion sizes, breastfeeding, school physical education, recreational spaces, walking as well as countering excess television viewing and the food industry's pernicious marketing.  That'll take blocking and tackling by schools, employers and local governments.

The overly perceptive DMCB also thought it detected the outlines of girdles under some of the contestants' spandex. Because human skin can stretch to accommodate increasing body volume, the loss of large amount of fat from under the skin can leave patients with an unsightly saggy exterior.  While the web is replete with unproven cures, the only viable option is plastic surgery. The DMCB couldn't find any population-based research that sheds light on how many formerly obese persons become baggy and how many go on to need surgery, but Google "obesity" + "compression garment" and the results suggest this is a growth industry.  Despite their success at slimming down, the DMCB suspects that many of These Biggest Losers may have lingering body sculpting issues to deal with.

A Population-Based Care Management Lesson: What Telephonic Disease Management Lacks In Individual Effectiveness Is Made Up By It's Greater Reach

What did that study show?

In yesterday's post on the role of telephonic disease management for obesity, the Disease Management Care Blog pointed out that POWER was a landmark study that demonstrated that remote lifestyle counseling performed as well as traditional face-to-face counseling.

A New England Journal of Medicine editorial accompanying the POWER article points out that there may have been an additional factor that explained the results: patient attendance at the in-person counseling sessions dropped off precipitously as the trial progressed (an average of only 2 out of 24 scheduled visits after the seventh month), while the telephonic approach achieved 16 out of 18 scheduled contacts.

The DMCB agrees and suggests this is an additional virtue of remote telephonic disease management.  While in-person counseling may have more of an individual impact, it does little good if  patients no-show.  In contrast, "high volume" telephonic counseling may have more of a population-based effect, because a lower intensity intervention has greater absolute impact if it's delivered to more persons.

NIH scientist Susan Yanovski's editorial falls short on capitalizing on that insight.  While it grudgingly points out that POWER shows "PCPs can deliver safe and effective weight-loss interventions in primary care settings," it neglects to mention the two important implications of POWER:

1) non-physician team members acting collaboration with PCPs are an important resource in the national battle against obesity and

2) offering a variety of communication channels increases reach and gives more patients new and effective options to access anti-obesity programs.

Lessons From The Practice-based Opportunities for Weight Reduction (POWER) Study: More Evidence of the Effectiveness of Remote Care Management for Obesity

"I need to call someone..."

The Disease Management Care Blog apologizes in advance for a long post about an important study comparing two state-of-the-art weight loss interventions.  Get some caffeine and hang in there.  If you are interested in the science of disease management and its role in obesity, you will not be disappointed.

Talk to some of the Ayatollahs dominating the academic medical-industrial complex about telephonic disease management and they'll give you the same look that they give to something unsightly that they just discovered on the end of their finger after rubbing their nose.  The idea that some remote (ugh!), telephone-based (bleh!) for-profit (yuck!) company could contribute anything to their vision of the health delivery is health policy apostasy.

But what how does this ideology stack up against the evidence?  

Until recently, we haven’t really known because there were few head-to-head comparisons of traditional “disease management” vs. traditional patient counseling.  But now we have the just-published POWER (“Practice-based Opportunities for Weight Reduction” study that was funded by the NHLBI and (whoa!) Healthways.  The authors were from Johns Hopkins University, which has a long-term consulting agreement with Healthways. They had final say on the research methodology and the paper's contents.

POWER was a prospective clinical trial that randomly assigned patients to one of three weight loss intervention strategies.  One consisted of “remote” telephonic treatment counseling, the second provided in-person counseling and the third was a control group.  The in-person sessions were provided by Johns Hopkins employees while the remote telephone counseling was provided by Healthways.

Study patients with obesity and at least one risk factor (hypertension, hyperlipidemia or diabetes) were recruited from six Baltimore primary care practices from 2008 through 2009.

All the interventions used basic nutritional and exercise guidelines that were delivered with state-of-the art “social cognitive theory,” "behavioral self-management,” “positive reinforcement” and “motivational interviewing.” Both of the intervention groups had access to a web site with learning modules plus feedback. If there was no log-on to the web site every 7 days, patients were sent a reminder email. 

Persons in the disease management-style remote support arm of the study got 12 weekly calls lasting 20 minutes for three months, which was followed by 3 monthly calls.   Persons assigned to the traditional in-person coaching arm got nine group sessions and three individual sessions over the 3 months followed by one group and two individual monthly sessions over three months. 

Participants’ weight loss was assessed at 6 and 24 months.

The patients' primary care physicians received summary reports and encouraged their patients’ participation.

Readers should note that this was an “effectiveness” trial.  Unlike “efficacy” trials, the protocol dispensed with the usual run-in period or making sure patients were adherent to the protocol before or during the study.

1370 persons were screened and 415 were randomized.  64% were women, the mean age was 54 years, 41% were black, 97% had commercial insurance and the mean BMI was a hefty 36.6.

After randomization, there was some drop out: 366 were weighed at 6 months, 355 at 12 months and 392 at 24 months. 

At 6 months: the control group lost 1.4 kilograms (kg) while there was 6.1 kg lost in the remote support, and 5.8 kg. lost in the in-person group.  That's 3.1 lbs vs. 13.4 lbs vs. 12.8 lbs.

At 24 months, the weight loss .8 kg in the control, 4.6 Kg in remote support and 5.1 Kg for in-person.  That's 1.8 lbs, 10.1 lbs and 11.2 lbs. That translates to body weight changes of 1.1%, 5.0% and 5.2%.  The percent of persons hitting at least 5% weight loss was 18.8% in the control group, 41.4% in the in-person support group and 38.2% in the group getting remote support. 7.8% of controls, 27.5% and 18.8% of controls, remote and in-person support patients, respectively, reached a BMI less than 30  

There was no statistically significant difference in weight loss outcomes between the two intervention groups.  In other words, the small changes between the disease management and in-person counseling could have been the result of chance.

What can readers conclude?

1.  This was a solidly performed study with important implications for a still-evolving national strategy in the battle against obesity.  If an intervention can lead approximately 40% of persons to lose 5% of their weight over two years, maybe the science of non-invasive weight reduction has gotten to the point where insurers should cover it.  While the DMCB remains suspicious about “mandates” and “the minimum benefit,” there are other policy levers that could be pushed to make this happen.  This is doubly true when you think about the costly alternatives of drugs and weight loss surgery.

2.  Seen through the lens of a disease management vs. in-person counseling competition, the industry’s “best” (Healthways) went toe to toe with the health system’s best (Johns Hopkins) and it was a tie.  When it comes to weight loss, it now comes down to who can do it cheaper and who can scale it.

3.  While this was a solid study, readers should be aware of its imperfections.  Since there were so few patients on Medicare or Medicaid, we don't know how this would work in patients with public insurance. This was not double blinded, so it’s possible that the outcomes were skewed because patients and their doctors were aware of their assigned treatment arm. The drops-outs' weights went unmeasured and their data could have changed the results.  There was a high reliance on group sessions in the "in-person" arm of the study, which may not be as effective as one-on-one counseling. The in-person sessions were also “remote” from the PCPs’ offices and may have been a poor substitute for the one-on-one counseling envisioned for a robust PCMH.  Successful weight loss is usually defined at 10% of body weight at one year instead of 5% at 2 years.  It’s also difficult to discern the relative contribution of the web site vs. the physician support vs. the nurse counseling.  We don’t know what happened to the patients’ blood pressure, cholesterol levels or their blood glucose control.  Finally, Hopkins had a doubtful but potential conflict of interest in a study that showed non-superiority vs. one of their customers.

4 While the DMCB doesn’t want to quibble, close scrutiny of the p-values in a table comparing the percent of persons reaching a BMI less than 30 for the in-person vs. remote support cohorts shows that it came quite close to being statistically significant at p = .07.  In other words, Healthways (27.5%)  almost beat Johns Hopkins (18.8%).  Using the same criteria in this study widely hailed as proving that Group Health’s medical home saves money, Healthways did beat Johns Hopkins.

5  Healthways deserves kudos for submitting to and committing resources to a clinical trial.  To the DMCB, the search for scientific truth is a price of doing business.  Their shareholders may think that cash is better spent on pursuing customers or driving efficiencies, but this research is an investment that will yield returns over the long run.  Other for-profits "get it" and so does Healthways.  The only question is why isn't this spashed on the company's web site?

6  If both interventions are equivalent, the DMCB suggests that they are not necessarily exclusive.  A truly enlighted approach to this would be to let patients choose which form of counseling they prefer.  What's more, if patients were allowed to choose, the amount of weight loss for both groups would probably be even greater.

7. Last but not least, this is further evidence that "disease management" has grown up.  This "DM Ver 2.0" is based on far more sophisticated principles of behavior change than those used in the Medicare Health Support debacle.  What's more, this Johns Hopkins paper reminds us that physicians, in the course of routine patient encounters, are simply not an option when it comes to weight loss counseling.  They're too busy and their job is to provide a supporting role.

"POWER" - one more acronym and one more piece of evidence to use in defense of disease and population-based care management.

Practical Approaches to Obesity Care and Chronic Illness In Busy Clinical Settings: Three Key Ingredients

If anything is true about the population health management service providers, they are constantly looking for better ways to fit their programs into busy clinical settings.

That's why this article on New and Emerging Weight Management Strategies for Busy Ambulatory Settings, courtesy of the American Heart Association, should be "must" reading for the vendor industry.  It's chock full of practical advice on how to "engineer" the PHM-physician partnership. While the focus of the article is on a practical approach to obesity, its approach can be applied to other conditions, such as diabetes or tobacco abuse. 

Among the three key lessons that resonated with the physician Disease Management Care Blog:

1. Providers and PHM vendors should make liberal use of surveys outside of the provider-patient encounter.  The surveys should include a assessment of readiness to change and measures of baseline behaviors.  In the specific area of weight-loss, there is a short 5 item survey (go here, then Table 1 and then scroll to the 3rd of 4 lists) that assesses readiness that can then be paired with measures of diet and exercise knowledge and activity.  By the way, the paper has other references that describe other validated surveys that can used in weight management.

2.  The physician's role is important because he or she can non-judgementally endorse, encourage and even "medicalize" the patients' interest in lifestyle change  That being said however, "collaborative approaches that involve physicians, nurses, or other providers" can be first stop for the assessing the survey results and with tailored counseling and follow-up that practically matches the expertise of a physician.  In other words, the docs don't need to do it.

3. The "internet" is emerging as an important option. It works best if it offers education, enables self monitoring, provides individualized goals, builds on motivation and has peer support.  It also helps if there is a "live" person somewhere in the loop.  There are some promising handheld device "apps" too.

While no one can argue that obesity is an important health issue and that primary care physicians have an important role to play, it's difficult to address it in the usual course of a doctor-patient encounter.  The good news, however, is that if you call a busy doc up and point out that assessments can be done via survey, that there are effective counseling strategies that involve other health professionals and that the internet is a resource, they'll endorse the approach.

Good news for the vendors, the docs and, most importantly, for the patients.

Four Reasons Why “Loss Aversion” Could Be An Effective Weight Loss Approach in Work Site Wellness Programs Targeting Obesity

Who's Going To Pay For This?

Given the economic costs associated with obesity, should we pay persons to lose weight in the hope that this will result in a long-term return on investment?  While that may be a good idea, the Disease Management Care Blog doubts commercial or government insurers will ever pay people to diet.

Yet, that doesn’t mean that we can't leverage “behavioral economics” in wellness programs.  That brings the DMCB to this interesting gem of a study by Leslie John and colleagues that was reported in the Journal of General Internal Medicine titled “Financial Incentives for Extended Weight Loss: A Randomized Controlled Trial.”  Even though the results were ultimately disappointing, the approach that was used may have considerable merit.
 
The DMCB explains.

"Loss aversion" is the well-known tendency of persons to attach greater value to economic losses than gains.  The authors capitalized on this by testing the impact of a “deposit contract” on 66 obese Philadelphia VA patients who put their own money at risk.  This was a 32 week (24 weeks of weight loss followed by an 8 week maintenance phase) trial that randomly allocated participants to one of three treatment arms:

1) a contract in which participants contributed up to $3 per day for a month to a fund that was matched 1:1 by the researchers.  The participants had to report their weight on a daily basis by telephone.  They were given credit for the day if their weight was equal to or less than a daily weight loss goal that was configured to ultimately result in a loss of 24 pounds in 24 weeks.  After each call, participants were given feedback via telephone text message.  There was a weigh-in at the end of each month.  If the weight target for the month was not met, all the money was forfeited.  The 24 weeks was followed by an 8 week period of weight maintenance that was described to the participants as “maintenance of weight loss period”

2) the same contract but there was no description of the 8 week period as “maintenance” and

3) a concurrent control group.
 
22 persons were assigned to each of the three treatment arms.  Between 18 to 19 of each of the three groups were male.  The the BMI ranged between 34 and 35 with an average weight of around 230 lbs. 
There was no difference in the weight loss at 32 weeks for the two treatment arms of the study, with a mean weight loss of 9.7 and 7.8 lbs, respectively.  During the same period, however, the control patients only lost 1.2 lbs.  Three months into the study, 50% of the intervention patients who were not meeting target chose to continue contributions even as they were falling behind.  Once the program was over, persons returned 36 weeks later for a final weigh-in and most regained their weight.  The forfeited money was evenly distributed to participants that had lost 20 or more lbs. during the study.

As the DMCB said, this was a disappointing study.  Yet, the DMCB wonders if this approach couldn’t be successfully adapted to a typical employer-sponsored obesity wellness program. 

Here’s four reasons why:

1) One of many building blocks: there may be something to the use of behavioral economics in modern psychological approaches to behavior change.  While the purpose of this classic randomized clinical trial was to assess the impact of a single discreet financial incentive, wellness program architects understand that interventions such as this can be combined with others, resulting in a synergistic approach that is greater than the sum of its parts.  Therefore, while it doesn’t seem to work as a stand-alone program at the Philadelphia VA, it could work as a program component at a worksite wellness initiative.

2) Show me the money: employers are constantly looking for approaches in which employees have “skin in the game.”  The idea that persons would put up their own money on behalf of their own wellness is a compelling concept that should gain the approval of the flintiest hard-nosed CEO.  In fact, it appears there is a good chance this approach could actually net some money.  The DMCB says give it to charity.

3) You, yes you, can plan, execute, evaluate and adjust this: the infrastructure necessary to support an intervention such as this is well within reach of employers, who could use standard payroll deductions, employer matching, networked workplace weight scales and corporate intranet supported feedback.  They also have the data systems that could be used to support an observational data base or a quasi-experimental study to assess whether the program is meaningfully successful.

4) Part of the menu (no pun intended): Last but not least, the DMCB doesn’t think there is any single approach to weight loss.  Some persons may have a psychological profile that makes them better suited to "loss aversion" as a weight loss strategy.  Perhaps this could be measured using a health risk assessment.  By offering this side by side on a targeted basis along with other weight loss program options, the DMCB thinks an employer could achieve even greater success than with any single “one size fits all” strategy.

The Future Burden Of Disease From Obesity May Be Underestimated (plus, how to sound like a very smart statistician)

No doc office is complete without this

In yet another instance of the medical literature being an endless font of obscure statistical jargon, check out this article in that wacky policy journal, Health Affairs, and say hello to the term "three dimensional forecasting."

Against all odds, the intrepid Disease Management Care Blog will attempt to wrestle this tricky theoretical tomfoolery to the ground, examine the implications for the obesity epidemic and, best of all, once again demonstrate how obscure epidemiologic phrasing can be used against foes and fools alike.

The Past As Prologue To The Future

According to authors Eric Reither, Jay Olshansky and Yang Yang, the accuracy of of "two dimensional" statistical trending is blunted by an underlying assumption that the trajectory of past data trends will continue into the future.  One example is the unrelenting upward march of national health care costs (which explains our national interest in "bending the trend").

Obesity

In this article, the authors apply their more accurate "three dimensional" approach to assessing the future national risks that are associated with obesity.  By way of background, the DMCB found this classic two dimensional graph that projects a 70% rate of obesity in the U.S. by 2020.  When the association between obesity and premature heart disease is considered, it's easy to conclude that that there could be a significant shortening of life expectancy in the coming decades.

Using The 3rd Dimension To Check Out The Future

Reither et al says it's much worse than that.  Their "three dimensional" methodology mathematically includes the burden of additional risk factors (for example, the prevalence of childhood obesity) that are present today that, in turn, could act as yet-unseen or "latent" drivers of more risk in the future.  This is a step up from the basic "two dimensional" modeling that bakes in past assumptions about improving overall life expectancy and ignores today's simmering time-bombs built of pizza, hot dogs and pop.

Yikes

Their conclusion?  They applied their modeling by testing it on past heart disease risk factor data and compared their predictions of the incidence of coronary artery disease with today's real incidence.  They found a surprisingly good fit.  Based on the fit of these data, they warn that the U.S. public health community's reliance on old statistical approaches is probably underestimating what we should be planning for in the future.  They recommend that "three dimensional modeling" be more broadly used and that we start by looking at obesity.  Based on some other research, they point out that we may be underestimating the projected decrease in life expectancy from obesity by as much as much as five years.

Enter The Institute Of Medicine

Speaking of which, the IOM has just released a report that lists interventions that have been shown to blunt the incidence of childhood obesity.  Children should be screened (two measures are weight for length or BMI at the 85th percentile), be encouraged to increase their physical activity (15 minutes per hour in day care for example; community outdoor recreation areas), engage in healthy eating habits (for example, attention to portion sizes) and be protected from predatory food industry marketing.  You can find lots of good stuff here; no obesity prevention program is compete without the IOM recommendatons.

3rd Dimension Verbal Swordsmanship

Armed with the concept that standard projections based on linear-statistical trending may be unequal to the task of assessing future risk, DMCB readers can now challenge know-it-all speakers, faux-expert consultants and tiresome academics by stopping them dead in their tracks - as early as PowerPoint slide 2.  Anytime you see a graph that has a dotted line extending up and into the future, you can raise your hand and ask if the plot is based on shabby two-dimensional modeling.  No boring meeting is complete without the threat of this kind of showstopper:

Er, excuse me Doctor Pintminded, but you seem to assume that the future prevalence of diabetes will be [insert number here] but does that account for present day risk factors that are typically included in a three dimensional analytic estimate of future burdens of disease?

Happy Hunting!

Image from Wikipedia

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)