Tag Archives: obesity

IOM Unveils Hot Reads in Time for Summer

In case you’re looking for something more meaningful to read this summer than Fifty Shades of Grey or Abraham Lincoln: Vampire Hunter, The Institute of Medicine has released some dandy reports suitable for reading or for hiding those trashy beach novels.

First up, in May, IOM released Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation. The report focuses on five critical goals for preventing obesity:

  • integrating physical activity into people’s daily lives,
  • making healthy food and beverage options available everywhere,
  • transforming marketing and messages about nutrition and activity,
  • making schools a gateway to healthy weights, and
  • galvanizing employers and health care professionals to support healthy lifestyles.

The committee outlined specific strategies include: requiring at least 60 minutes per day of physical education and activity in schools, industry-wide guidelines on which foods and beverages can be marketed to children and how, expansion of workplace wellness programs, taking full advantage of physicians’ roles to advocate for obesity prevention with patients and in the community, and increasing the availability of lower-calorie, healthier children’s meals in restaurants.

Also in May, IOM published Ethical and Scientific Issues in Studying the Safety of Approved Drugs. In response to the passage of the Food and Drug Administration Act in 2007, the FDA asked the IOM to evaluate scientific and ethical aspects of safety studies for approved drugs. The IOM concluded that the FDA’s current approach to drug oversight in the postmarket setting is not systematic enough and does not ensure that benefits and risks of drugs are assessed consistently over the drug’s life cycle.  “Adopting a regulatory framework that is standardized across all drugs, yet flexible enough to adapt to regulatory decisions of differing complexity, could help make the agency’s decision-making process more predictable, transparent, and proactive. These changes could allow the FDA to better anticipate postapproval research needs and improve drug safety for all Americans.”

Finally, for the ambitious reader, the IOM had just released the discussion paper A CEO Checklist for High-Value Health Care. Despite risking costs, healthcare remains suboptimal in many areas. “To aid and accelerate the system-wide transformation necessary, we have assembled what we are calling “A CEO Checklist for High-Value Care” (the Checklist). The Checklist’s 10 items reflect the strategies that, in our experiences and those of others, have proven effective and essential to improving quality and reducing costs. They describe the foundational, infrastructure, care delivery, and feedback components of a system oriented around value, and represent basic opportunities—indeed obligations—for hospital and health care delivery system CEOs and Boards to improve the value of health care in their institutions.”

The 10 items include:

  • Governance priority—visible and determined leadership by CEO and Board
  • Culture of continuous improvement—commitment to ongoing, real-time learning
  •  IT best practices—automated, reliable information to and from the point of care
  • Evidence protocols—effective, efficient, and consistent care
  • Resource utilization—optimized use of personnel, physical space, and other resources
  • Integrated care—right care, right setting, right providers, right teamwork
  • Shared decision making—patient–clinician collaboration on care plans
  • Targeted services—tailored community and clinic interventions for resource-intensive patients
  • Embedded safeguards—supports and prompts to reduce injury and infection
  • Internal transparency—visible progress in performance, outcomes, and costs

Kerri Wachter (On Twitter @knwachter)

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Filed under Drug And Device Safety, Health Policy, health reform, IMNG, Primary care

The U.S. Obesity Epidemic and Surging Liver Cancer

If there is one truism that trumps everything else these days about U.S. health, it’s that America is a chubby country that keeps getting fatter.

The consequences seep into every corner of the nation’s medical state, including the surprising fact that obesity and the type 2 diabetes it causes are likely pushing up the incidence of liver cancer—hepatocellular carcinoma—to unprecedented heights.

courtesy Wikimedia Commons

When I covered Digestive Disease Week in San Diego recently, one of the biggest stories I heard was that U.S. liver-cancer rates tripled from 1975-2007, and that the numbers continued to rise from the mid to the late 2000s. (My full report on this is here).

Granted, factors other than just obesity play into the liver cancer surge, notably the sizable number of Americans infected with either hepatitis B or C virus, and the fact that as they age their risk for developing hepatocellular carcinoma rises.

But new U.S. infections by hepatitis B and C are largely under control these days (although people infected elsewhere continue to emigrate to the United States). The part of the booming liver-cancer story that is by no means under control is the obesity part.

Every time I see a new CDC map for U.S. obesity prevalence, the colors on it keep getting redder and darker (the CDC’s code for higher prevalence rates).

courtesy CDC

courtesy CDC

Earlier this year, the CDC reported a 36% obesity prevalence rate for the entire U.S. population–and still on the rise–and just a few weeks ago we heard that obesity among children and adolescents had hit a new high of 17%. With obesity seemingly on an unchanging upward trajectory, one can only wonder what rates of liver cancer it might produce in the future. Obesity carries a special relationship with the liver, and it’s not pretty. Just consider any goose headed to a foie-gras future.

Until now, the evidence linking obesity and liver cancer, and type 2 diabetes and liver cancer has been epidemiologic. Compelling, but just an association. At DDW, a new study provided more observational data on the diabetes-liver cancer link, and while still circumstantial it further supports the notion and also carries an intriguing punchline.

The study, done in Taiwan, examined 97,000 hepatocellular carcinoma patients and 195,000 matched controls. The analysis showed that people with diabetes had a two-fold increased risk for liver cancer compared with those without diabetes. Even more striking, the analysis also showed that people with diabetes treated with the oral hypoglycemic drug metformin had their risk for liver cancer cut in half compared with those not on metformin, and those with diabetes treated with a glitazone drug (such as pioglitazone–Actos) had their risk cut nearly in half.

The best solution would be if people avoided obesity and type 2 diabetes all together. Both conditions cause a lot of medical problems, and this new evidence indicates more strongly than ever before that liver cancer is one of them.

—Mitchel Zoler (on Twitter @mitchelzoler)

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Filed under Endocrinology, Diabetes, and Metabolism, Epidemiology, Gastroenterology, IMNG, Internal Medicine, Internal Medicine News, Oncology

ED Patients Blind to Risks of Being Overweight

American tongues start wagging whenever the latest starlet puts on a few pounds, but we appear loathe to discuss our own ever-increasing waistline.

A study of 453 adults presenting to a Florida ED found that 58.5% of overweight/obese African American and Caucasian men and women feel their weight is not a health issue AND have never discussed their weight with their healthcare provider.

The average BMI in the study was 29.5 kg/m2, mean weight 184 pounds, 61% were female and the average waist circumference an undignified 39.5 inches.

Given those stats, you’d think these patients had gotten an earful from their provider, but not so.

Overall, 38% of all patients reported their weight to be unhealthy, but only 28% recalled being told so by their provider, University of Florida emergency physician Dr. Matthew Ryan reported at the recent meeting of the Society for Academic Emergency Medicine in Chicago.

It’s possible that some physicians may be afraid to bring up weight for fear their patients will scurry off to a “kinder, gentler” provider. Others may simply be short on time. Yet even when docs did start the conversation, some patients just couldn’t make the connection between obesity and health risks.

Among patients told by their provider they were overweight, 77% believe their present weight is damaging to their health, yet 23% still believe their weight is not unhealthy.

Dr. Ryan points out there’s an obvious disconnect between patients’ perceptions of their weight and their actual weight and current health, and suggests that “the first line of action toward confronting the mounting obesity epidemic in the U.S. is clear patient-provider education.”

The chaotic environment of the ED may seem like an unlikely place to help increase patient awareness about weight-related medical issues or to provide weight-loss counseling, but there may just be something to the “Willie Sutton rule” that teaches, not just bankrobbers, but medical students to focus on the obvious.

As part of the study, the investigators also measured the prevalence of obese patients presenting to their ED in order to compare it to state and national prevalence rates. It reached a whopping 38%, towering over the already hefty 26.6% obesity rate reported for the general population in Florida in 2010 by the CDC.

To their knowledge, the authors say no studies have directly measured the obesity prevalence in the ED. Thus, the ED population may be poorly represented in existing national healthcare studies, which are largely community-based. Moreover, the obesity prevalence may be higher than indicated by studies like the CDC’s that rely on self-reported height and weight.

Given the author’s findings in the ED, that’s a very real and chilling possibility.

The research was supported by a University of Florida Clinical and Translational Science Institute grant.  Dr. Ryan reported having no conflicts of interest.

– Patrice Wendling

 

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More Docs Are Asking Patients to Exercise

Physicians are getting better at advising adults to exercise.

Photo courtesy National Cancer Institute/Bill Branson

In 2010, 32.4% of adults in the United States who had seen a physician or other health care professional in the past year had received a recommendation to begin or continue to do exercise or physical activity, up from 22.6% in 2000. At each time point, women were more likely than men to have been advised to exercise.

The findings, published this month as a National Center for Health Statistics Data Brief, come from the National Health Interview Surveys conducted in 2000, 2005, and 2010.

Between 2000 and 2010 the percentage of patients aged 85 and older who received a “get fit” recommendation from a physician nearly doubled from 15.3% to 28.9%. The percentage of patients aged 18-24 years receiving such a recommendation also increased during the same time period, but to a lesser extent (from 10.4% to 16.1%).

The report also found that the percentage of adults with hypertension, cardiovascular disease, cancer, and diabetes who received exercise advice from a physician increased between 2000 and 2010.

“Trends over the past 10 years suggest that the medical community is increasing its efforts to recommend participation in exercise and other physical activity that research has shown to be associated with substantial health benefits,” the report states. “Still, the prevalence of receiving this advice remains well below one-half of U.S. adults and varies substantially across population subgroups.” 

 — Doug Brunk (on Twitter@dougbrunk)

Photo courtesy National Cancer Institute Visuals Online

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Filed under Cardiovascular Medicine, Family Medicine, IMNG, Practice Trends, Primary care

Attacking Obesity

The diversity of disciplines represented at the annual meeting of The Obesity Society parallels the reach of the obesity epidemic itself.

Primary care physicians, endocrinologists, pharmacologists, bariatric surgeons, psychiatrists, psychologists, social workers, educators, nutritionists, and food service workers have spent the past five days in Orlando, Fla., wrestling the obesity beast, trying to shed light on why it is so intractable and discussing interventions that may tame it. Following are a few observations from the meeting:

Courtesy of the Rudd Center for Food Policy & Obesity

1. Although obesity in the United States is being attacked full-force from all sides with drugs, surgery, and psychosocial and behavioral interventions, its prevalence is expected to continue to climb as those born in the 1980s (when the obesity epidemic began) age into their “prime years of obesity incidence,” according to data presented by Whitney Robinson, Ph.D. of the University of North Carolina at Chapel Hill. Dr. Robinson and colleagues used height and weight data measured from 1971-2008 in the National Health and Nutrition Examination Survey (NHANES) to quantify cohort effects as a way to estimate obesity trends. They determined that cohorts born in the 1980s had significantly increased obesity risk versus those born in the late 1960s. The cohort effects, which are those not attributable to the additive effects of age and period, for the 1979-1983 and the 1984-1988 birth cohorts relative to the late 1960s cohort were 1.18 and 1.21, respectively.

Although it is well understood that period effects representing widespread environmental influences have driven increases in obesity prevalence, Dr. Robinson reported, “obesity in adults born in the 1980s shows positive cohort effects as well.”  This finding suggests that even if the obesigenic environment stabilizes, obesity prevalence could continue to increase, particularly in the absence of widespread environmental change.

2. Technology is becoming an ubiquitous weapon in the obesity armamentarium, as evidenced by the many presentations focusing on computer-, Internet- and even smart phone-based strategies. For example, in one late-breaking presentation, Kelly H. Webber, Ph.D. and Dr. Stephanie A. Rose of the University of Kentucky, Lexington, described a pilot study comparing the impact of an Internet behavioral weight loss program alone and in combination with portion-controlled food provision. The study demonstrated that the short-term effect of the combination approach was particularly beneficial.

Similarly, Melissa A. Napolitano, Ph.D. of Temple University in Philadelphia presented a pilot trial of a virtual reality-based psycho-educational intervention for modeling weight loss skills. The findings demonstrated short-term success, with outcomes approximating those found in conventional behavioral weight loss programs.

Finally, a comprehensive evaluation of available iPhone apps for weight loss, presented by Penny Deck, a Ph.D. student at Simon Fraser University, demonstrated the considerable variation in the degree to which the applications follow evidence-based recommendations for weight loss. In particular, she noted, “most of the apps demonstrated poor adherence to such recommendations as basing goals on behaviors vs. weight and advocating small sustainable changes.”

All of the technology interventions are still too young to have long-term outcomes data. It is therefore too early to determine whether their short-term efficacy is a function of the interventions themselves or their novelty. In a presentation describing the apparent benefits of a church-based telemedicine weight loss intervention, Gary Foster, Ph.D., of Temple University observed that most behavioral weight loss interventions are effective in the short term, “but what we really need are long-term studies to evaluate their continued efficacy over time.”

3. Anti-obesity prejudice is pervasive in all sectors of society, including among individuals and organizations in positions of influence. In response to a query from an attendee about the FDA’s reluctance to approve amphetamines for weight loss but not for attention deficit disorder, Dr. George Bray, chief of the division of Clinical Obesity and Metabolism at Pennington Biomedical Research Center in Baton Rouge, La., attributed the double standard to the cultural perception that obesity is an aesthetic problem. “ADHD is viewed as a disease, while obesity is perceived to be a moral deficit,” he said.

The cultural stigma is perpetuated by the news media and even by medical professionals through the photographic and video portrayal of overweight people using headless body shots, primarily focusing on unflattering views of the abdomen or lower body, often in sloppy attire and eating unhealthfully, according to Dr. Arya Sharma, chair in obesity research and management at the University of Alberta in Edmonton, Canada.

To counter the prejudice, the Rudd Center for Food Policy and Obesity at Yale University and The Obesity Society have developed a document called Guidelines for the Portrayal of Obese Persons in the Media, which was available in the meeting press room. The Rudd Center also offers a gallery of more positive images that it makes available to the press.

–By Diana Mahoney

 

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Filed under Cardiovascular Medicine, Clinical Psychiatry News, Endocrinology, Diabetes, and Metabolism, Epidemiology, Family Medicine, Gastroenterology, IMNG, Internal Medicine, Pediatrics, Primary care, Psychiatry, Surgery

Street Food May Contribute to Obesity. Surprise.

What about the guys selling food on the street? That was the primary research question posed by Dr. Sean Lucan of Albert Einstein College of Medicine in New York and colleagues as part of a study evaluating whether the fare offered by mobile food vendors in New York contributes to an “obesigenic” food environment. Hmm. Did we really need a study to give us the answer?

Courtesy Wikimedia Commons/Totya/Creative Commons License

The team scoured the Bronx looking for mobile food stalls during the summer and fall of 2010, querying the vendors about what they sold, then assessing the health value of the items. “Only 10% of vendors selling prepared food sold any produce,” Dr. Lucan reported in a poster presentation at the annual meeting of the Obesity Society in Orlando.

In addition, low-fat milk and whole grains were “essentially absent” among the 372 food vendors surveyed, he said. Items high in fat, calories, salt, and/or added sugar were plentiful while fruits and vegetables were limited. Of the 28% of vendors offering any fruit or vegetable, one offered a single whole grain item, while all offered multiple prepared and processed foods. The investigators concluded that the overall contribution of street food vendors “may be unhealthy and obesigenic on balance.” Go figure.

A more enlightening study might consider whether consumers would bite if more healthful street food options were available.  

–Diana Mahoney

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Filed under Endocrinology, Diabetes, and Metabolism, Family Medicine, Gastroenterology, IMNG, Internal Medicine, Pediatrics, Primary care

Are You Serving Your LGBT Diabetes Patients?

Are most health care providers attuned to the needs of their diabetes patients who are lesbian, gay, bisexual, and transgender (LGBT)? Does it matter? No and yes respectively, according to certified diabetes educator Theresa Garnero.

Rauchdickson photo via Flickr Creative Commons

More than half of medical school curricula include no information about LGBT people, and most multidisciplinary professionals have not received tools to care for LGBT individuals, Ms. Garnero said at the annual meeting of the American Association of Diabetes Educators.

A number of factors that increase the risk for developing diabetes are highly prevalent among people who are LGBT. For example, obesity and polycystic ovary syndrome (PCOS), both strong risk factors for type 2 diabetes, are more common among lesbians than among heterosexual women. Indeed, in one study, PCOS was identified in 38% of lesbians vs. just 14% of heterosexual women.

Antiretroviral drugs used to treat HIV/AIDS often lead to insulin resistance and type 2 diabetes. Men on HIV treatment have four times the risk of diabetes as do HIV-negative men. Moreover, cigarette smoking, alcohol abuse, and illicit drug use, all of which particularly endanger the health of those with diabetes, are frequent behaviors among LGBT individuals.

Depression is common in both LGBT individuals and people with diabetes. Withholding of insulin among closeted LGBT youth with type 1 diabetes could be a suicidal gesture rather than diabulimia.

How many LGB people have diabetes? It’s extremely difficult to obtain statistics – and there are virtually none for transgendered people – but based on self-reported health data, roughly 1.3 million LGB people have diabetes, a number approximately equal to that of type 1 or gestational diabetes, Ms. Garnero said.

So why does it matter? Lack of awareness and presumption of heterosexuality can lead to mistakes that alienate patients, such as lecturing a young lesbian with diabetes about the need for birth control or expressing negative attitudes toward patients who want to bring their same-sex partners to diabetes-education classes.

Importantly, patients who perceive that they can’t be open with their health care provider about sexual orientation may be reluctant to share other health-related information.

“Individuals who approach the health care system are already vulnerable from their illness … Intolerance is the last thing anyone wants when seeking health care. It is certainly not a part of the caring diabetes professional culture,” Ms. Garnero said.

What can the health care provider do? Placing a rainbow flag sticker or nondiscrimination statement that specifically mentions sexual orientation in the waiting room is a simple way providers can let patients know that they are LGBT-friendly. Other helpful information for providers can be found here.

Bottom line, she said: “All people with diabetes deserve the benefit of our expertise and access to ongoing support.”

-Miriam E. Tucker (@MiriamETucker on Twitter)

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Filed under Endocrinology, Diabetes, and Metabolism, Family Medicine, IMNG, Internal Medicine, Obstetrics and Gynecology, Primary care, Psychiatry