What Doctors Should– and Should Not– Say to Obese Patients

Below a remarkably candid and compelling essay by Emma Lewis titled “Why there’s no point in telling me to lose weight. ” It originally appeared in the January 2015 issue of BMJ (formerly the British Medical Journal).  Hat-tip to Helen Haskell, president and founder of Mothers Against Medical Error, who sent me Lewis’ piece.

In her editorial (cross-posted below), Lewis explains why she has “opted out” of the “weight-loss game.”  She confides that she has been “fat” since she was a child. She still remembers the humiliations, which continue to this day– especially when she visits a primary care doctor.

It doesn’t matter whether she is seeing the physician because she has broken an ankle or needs contraception. Inevitably, he or she brings up her Body Mass Index (BMI.) And when a GP admonishes her that she should diet and work out, he rarely asks what she eats now, or how much she exercises.  He doesn’t listen; he lectures.

In fact, Lewis does care about her health: she exercises regularly and has switched to a whole meal vegetarian diet. For years, she has been in good health. But her BMI remains above 30.

What Many Doctors Don’t Know—And What Even the Experts Don’t Understand

What these general practitioners don’t know is what doctors and scientists who specialize in obesity have discovered:  the vast majority of overweight patients cannot shed pounds—and keep them off—even in highly controlled experimental settings where patients diet and exercise under a doctor’s supervision.  As I explain in the post below two years after starting a diet, roughly 95% will have put all of the weight back on.

And even the experts who study the obesity epidemicdon’t understand why.

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Losing Weight—What the Experts Are Reluctant to Tell You – Part 1

Have you ever shed 15 or 25  pounds and, then, over the next year or so, put it all back on? Usually, we blame ourselves.

But, as I reported on HealthBeat in 2008, physicians who treat obese and overweight patients know that only about 5% of us are able to lose weight and keep it off—even in highly controlled experimental settings where patients diet and exercise under a doctors’ supervision. Over two years, 95% of us will put the pounds back on, and in some cases, add more.

A National Institutes of Health (NIH), working group study published in the January 2015 issue of the journal Obesity, confirms that:  “Despite advancements in our understanding of obesity, weight regain after weight loss remains the most substantial problem in obesity treatment – with both the body and the mind conspiring against individual efforts to maintain weight loss.”

                What Randomized Controlled Trials Reveal 

University of Minnesota Psychologist Traci Mann has spent 20 years running an eating lab and, based on her experience, she reports: “Long-term weight loss happens only to the smallest minority of people.”  

Indeed, when she and five other researchers analyzed outcomes for patients in randomized trails where one group dieted, and the other group did not, the studies showed that, after two years, the average patient on a calorie restricted regimen had lost only one kilogram, or about two pounds, while one third to two thirds of dieters had actually regained more weight than they lost. (In many of these trials, the patients not only cut calories, but also exercised.)

What about folks who combine intensive lifestyle changes with drugs designed to help us lose weight? “Studies show that patients on drug therapy lose around 10 percent of their excess weight,” but “the weight loss plateaus after six to eight months,” UCSF’s Medical Center reports. “As patients stop taking the medication, weight gain usually occurs.”

                              Low-Carb vs. Low-Fat Diets 

Does it matter which diets you try?

At one time, most physicians were convinced that fatty foods led to obesity, and a low-fat diet offered the best route to becoming svelte. But in recent years, a growing number of doctors and health advocates have begun to argue that increased consumption of sugar and refined carbohydrates is the most likely explanation for our obesity epidemic. 

Last summer WIRED published an impressive in-depth review of what we do and do not know about whether certain foods will make us fat.

The story notes that that in 2009, “Robert Lustig, a pediatric endocrinologist, rose to national fame after a 2009 lecture in which he called sugar ‘poison’ went viral on YouTube.

 Meanwhile, newer science has undermined the consensus that fat is all that bad for you. A recent meta-analysis published in the Annals of Internal Medicine found no clear evidence that eating saturated fat contributes to cardiovascular disease.”

What about carbs? “In trials, carbohydrate restricted diets almost invariably show significantly better short term weight loss,” WIRED reported, but “over time, the differences converge towards non-significance.”  In other words, the available evidence suggests that over the long term, both low-fat and low-carb diets fail.  

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Over-Eating: Confusing Cause and Effect–Does Overeating CAUSE You to Re-Gain Weight, Or Do You Eat More BECAUSE You Are Overweight?

Today, researchers are digging into what drives weight gain, and some are beginning to suggest that we have been confusing cause and effect.

What if it’s not overeating that causes us to get fat, but the process of getting fatter that causes us to overeat?”

Recently The Journal of the American Medical Association (JAMA) published a provocative piece that asked precisely that question. Shortly before publishing in JAMA, the authors, summed up their argument in a New York Times Op-Ed: “Always Hungry? Here’s Why.”  

There, David Ludwig, a professor of pediatrics at Harvard Medical School and director the New Balance Foundation Obesity Prevention Center at Boston Children’s Hospital, and Mark Friedman, vice president of research at the Nutrition Science Initiative did a superb job of distilling their argument into terms a layman can understand.

They suggest that chronic overeating represents a symptom rather than the primary cause of piling on the pounds. Indeed, Ludwig and Friedman argue, dieting itself may induce changes in our metabolism that leads us to regain weight when we begin to lose it.

They explain their theory:  When we eat hearty meals, “we lock . . . more calories away in fat tissue.” As a result, “fewer are circulating in the bloodstream to satisfy the body’s requirements.” In other words, there are not enough calories in our bloodstream to give us the energy to do what we want to do.

“If we look at it this way,” they continue, “it’s a distribution problem: We have an abundance of calories, but they’re in the wrong place. As a result, the body needs to increase its intake. We get hungrier because we’re getting fatter.” 

Ludwig and Friedman compare the process to what happens when patients suffer from “edema, a common medical condition in which fluid leaks from blood vessels into surrounding tissues. No matter how much water they drink, people with edema may experience unquenchable thirst because the fluid doesn’t stay in the blood, where it’s needed.

“Similarly,” they suggest, “when fat cells suck up too much fuel, calories from food promote the growth of fat tissue instead of serving the energy needs of the body, provoking overeating in all but the most disciplined individuals.”

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The Individual Mandate: Has the Obama Administration Silently Repealed the Rule that Virtually Everyone Must Have Health Insurance?

Obamacare’s critics continue to argue that the Affordable Care Act (ACA) will self-destruct.  Now, some claim that the mandate that uninsured Americans must purchase coverage– or pay a stiff fine— is so riddled with new “loopholes and exemptions,” that it no longer exists.

                                            14 New Waivers

When the ACA passed Congress in 2010, it offered a handful of basic exemptions to the mandate that everyone must be insured. For example, if the only comprehensive coverage available would cost more than 8% of a household’s income, the fine would be waived. Individuals who were in jail, or belonged to a recognized religious group that objects to all insurance, including Medicare and Social Security, also would be excused.  

But then, late in 2013, the administration quietly added some 14 new ways that uninsured Americans could dodge the fine. “This latest reconstruction” of the ACA received zero media coverage,” a Wall Street Journal editorial declared, “and the Health and Human Services Department (HHS) didn’t think the details were worth discussing in a conference call, press materials or fact sheet.”

Yet if the new waivers went largely unnoticed, reform’s opponents claim that the swelling list of escape clauses will have a huge impact. By 2016, they say, almost 90% of the nation’s 30 million uninsured will be able to ignore the mandate that they buy insurance—without paying the piper.  So much for universal coverage.

Just last week Bloomberg reported that some Republicans politicians now refer to the new list of loopholes as a “stealth repeal” of the individual mandate. To her credit, Bloomberg’s Caroline Chen points out the contradiction in the GOP’s arguments: the same critics who, in the past, argued that the mandate represented “unwarranted government coercion” now criticize it for being too “wimpy.” Can they really have it both ways?

                                       “Hardship Exemptions”

The new waivers were designed to help those who are facing hard times.  Some exemptions will suspend penalties for 3 months—others for a year.

Perhaps the most important waiver bails out low-income Americans who have the bad luck to live in a state that has refused to expand Medicaid.  Originally, the ACA stipulated that states must extend Medicaid to adults earning less that 138 percent of the federal poverty level ($27,310 for a family of three), with the Federal government paying the lion’s share of the extra cost. At the same time, the ACA set out to help low and middle-income families earning more than 138% of the FPL, by providing government subsidies designed to help them purchase insurance in their state exchanges.

But then, two years after the ACA passed Congress, the Supreme Court blind-sided reform’s architects by ruling that states could opt out of expanding the federal/state. program. No surprise, politicians in Red states saw this as an opportunity to undermine Obamacare.

Today, twenty-two states still are refusing to open the Medicaid umbrella to cover some of their poorest citizens. As a result, in many cases, only parents earning less than 50% of poverty ($9,893 for a family of three) qualify for Medicaid, while childless adults remain ineligible in almost all of these states.  (When Medicaid passed Congress in 1965 legislators decided that only “the worthy poor” should be covered. People who didn’t have children were not considered “worthy”.)

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Obamacare Fines: How to Escape a Hefty Penalty If You Really Can’t Buy Insurance

Already, the fear-mongers are sounding the alarm: If you don’t purchase exactly the type of health insurance that the Affordable Care Act (ACA) requires, come tax-time the IRS will slap you with a stiff penalty.

As I explain in the post below, the ACA mandates that if you’re not already covered, you must buy insurance that includes “essential benefits” such as hospitalization, maternity and newborn care, and mental health services. Ignore the mandate this year, and you will be fined when you file your taxes next year.

                                 How Much Would You Owe?

If  you opt out of purchasing insurance that covers you and your family in 2015, the penalty will equal Either:

“Whichever is greater” means that wealthier taxpayers will be required to pay 1% of their income, and as a result can easily wind up owing significantly more than $285. This doesn’t mean that millionaires would be fined tens of thousands of dollars. An affluent family’s penalty also is capped, at the average cost of bronze plans sold in state Exchanges nationwide.

In  2014, nationwide, the average bronze plan premium was $2,448 per individual and $12,240 for a family with five or more. This year, across the nation, average premiums were slightly higher, so a family of five earning more than roughly $145,000 would have to fork over a little more than $12,240.

                         If This Sounds Complicated, Turbo-Tax Makes it Simple

If, at this point, your eyes are glazing over, the good news is that you can calculate your penalty, quickly and easily, on Turbotax’s online calculator. Just type  in your income, zip code, and  the size of your household, and in about three minutes, TurboTax will tell you  the size of your fine—and, most importantly, whether you might qualify for an exemption to the penalty.

                                 How You Might Escape the Fine

The  chances that the IRS will fine you are slim. What the fear-mongers rarely mention is that, thanks to the many exemptions built into the law, only about 10 percent of the uninsured will owe a penalty. The Congressional Budget Office (CBO) estimates that in 2016,  just 4 million uninsured Americans will face fines, while 26 million will qualify for waivers. 

Recently, I wrote a piece for Consumer Reports listing some of the most common exemptions:

  •  if the lowest-priced coverage available to you, even after applying  a government subsidy, would cost more than 8 percent of your household’s income, the fine is waived;
  • –if you earn less than $10,150 (or $20,300 for a married couple) and so are not required to file income taxes you owe no fine and don’t even have to apply for a wavier;
  • if you were uninsured for less than 3 consecutive months, you will not be fined.

(As I explain in the post below,  this means that if you sign up for 2015 coverage by February 15 you will be insured as of March 1, and will not owe a penalty for 2015.) 

                       Little Known “Hardship Exemptions”               

On the Consumer Reports website, I also point out that late in 2013, the government added 14 new waivers

 

for people who have experienced personal hardships such as domestic violence, substantial property damage from a fire or flood, from a fire or flood, the death of a close relative, a utility cut-off, or bankruptcy.

Perhaps most importantly, the government is offering a one-year waiver to people who don’t qualify for Medicaid because they live in a state that has refused to expand the program under ACA rules.

To learn more about the hardship exemptions, how to apply for any exemption, and information on how you might escape the penalty, but still buy catastrophic insurance, read the rest of the post on Consumer Reports.org.

 

 

 

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It’s not too late to sign up for Obamacare- But if you wait much longer you could face a fine

 Note to HealthBeat readers: I have recently begun writing posts about healthcare and healthcare reform for Consumer Reports. Below, an excerpt from my latest post. M.M

It’s still not too late to sign up for insurance in your state’s marketplace. Open enrollment for Obamacare continues until Feb. 15. Meet that deadline, and you will be insured on March 1, with no penalty.

And if the plan you purchased in 2014 was automatically renewed on Jan. 1, you can still change your mind, comparison shop, and pick a new policy in February. There are lots of good reasons to shop around, as plans change from year to year.

Even better news: It’s not too late to apply for a tax credit that can help slash premiums. This year, nearly 9 out of 10 people who purchased insurance in state marketplaces have qualified for financial assistance. Last year, tax credits cut the average premium by 76 percent—to just $82 per month. Almost half of those who received subsidies wound up paying $50 or less. See if you might qualify for a subsidy.

Who has to pay fines?

Even if you don’t have insurance in January and February, you won’t have to pay a fine as long as you have health insurance in place by March 1.

How much will you owe?  Compare penalties to premiums in your zip code

Turbotax has created an online calculator that tallies the fine if you don’t buy insurance by Feb. 15.

To compare the fine to the cost of coverage, after subsidies, use the Kaiser Family Foundation’ premium calculator.

You will find links to both when you read the rest of this post on Consumer Reports.org.

 

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OBAMACARE ENROLLMENT (part 2) Who Will Remain Opposed to Obamacare in 2015? “Zero-Sum Thinking”

 

In 2015, I predict that Obamacare enrollment will soar, matching 2014’s success.

This may seem counter-intuitive. After all, in recent months, the public’s perception of Obamacare seems to have soured. The Henry J. Kaiser Foundation’s health care tracking poll for July reveals that 53% of those surveyed last month said they view the Affordable Care Act unfavorably—a jump of 8 percentage points since June.  July’s results mark the first time since January, that more than half of all Americans opposed the health reform law

Is this because people who have enrolled in the Exchanges are unhappy with the insurance they purchased?

No.

      Most People Who Signed Up for  Obamacare Are Happy

Just one month earlier a Kaiser Foundation poll showed that “71%” of those who have enrolled in insurance plans that comply with Obamacare’s rules “rate their coverage as excellent or good overall,” and “more than half (55%) say it is an excellent or good value for what they pay for it.”

This is in part because in the Exchanges, middle-income as well as low-income customers qualify for government assistance to help cover premiums. As a result, 87% of customers have received subsidies that come in the form of tax credits. 

Nearly six out of ten of Obamacare’s new customers were previously uninsured, Kaiser reports, while the remainder are “plan-switchers” – people who previously had individual market coverage and switched to new coverage after Jan. 1.  This group includes people who had their old policies cancelled as the ACA’s requirements kicked in, as well as people who switched for other reasons, including the availability of premium subsidies.

No surprise, customers who were forced to switch to a plan that meets Obamacare regulations are not as pleased as those who were previously uninsured. Yet nearly half of the “switchers” acknowledge that after using the tax credit, their new, more comprehensive Obamacare plan costs less than their old policy. This means that they are getting more for less. And I would predict that as they use their new policies ( and discover, for example, that preventive care is free)  many will become more enthusiastic.

Here is  the bottom line: “As a whole,” Kaiser observes, “enrollees are more likely than the public overall to have a favorable view of the ACA: they are roughly evenly split between positive and negative views (47% favorable vs. 43% unfavorable). By contrast, views among the general public are more negative than positive (38% favorable vs. 46% unfavorable.)

In other words, people who have had direct experience with Obamacare are more likely to support it. Those who have only read about reform are more likely to be opposed

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Border Crisis: Fictions v. Facts (Part 2 of “Children from Central America”)

Despite extensive media coverage, there is probably much that you don’t know about the history of the border crisis—and what we can or should do in response. Too often the headlines are designed to stir passions, rather than inform.

At the end of next week, Congress will leave for its five-week August Recess. Between now and then legislators will be debating the issues, and no doubt many of your friends will be taking positions.

Here are the facts you need when weighing what you hear–whether on television or at a neighbor’s barbecue.

  •  Are you aware that since President Obama took office, it has become harder for illegal immigrants to cross our Southwestern border? This is something Fox News doesn’t usually mention.
  •  Did you know that even if we deport the tens of thousands of children who have come here since last October, many refugee experts agree they’ll try again—and that other children will follow them? In other words, they say, deportation will not serve as a deterrent. These kids are running for their lives.
  • Are you aware that in the past the U.S. has backed military coups and paramilitary death squads in Central America? As democratically-elected governments toppled, constitutional order collapsed, and the gangs took over the streets.  Does this mean that we are in part responsible for the exodus of kids fleeing violence at home? That is a difficult question, but definitely worth thinking about.
  • Did you know that the most powerful gangs originated in Los Angeles?  In the 1990s, we began deporting these thugs (via ConAir), and dumped them back in countries ill-equipped to police them.
  • Had you heard that the kids coming in today are not trying to avoid border patrols? They are rafting, swimming, and walking into the U.S. in broad daylight. So the problem is not that we don’t have enough border patrols to “secure the border. “ The new immigrants are eager to turn themselves over to border officials. Why? In 2008, former President George W. Bush signed the “William Wilberforce Trafficking Victims Protection Reauthorization Act.” This bipartisan measure mandates that the border patrols cannot simply send unaccompanied minors from Central America back to their home countries. The U.S. government must try to find responsible relatives in the U. S. and place the children with them (or in foster homes) while they await a hearing before an immigrant court judge.

Understanding this law–and why it passed so easily in 2008—is key to understanding the legal and moral quandary that President Obama and Congress now face.

  • Finally, how many Americans are aware that, despite high unemployment rates in the U.S., we face a labor shortage? We need more immigrants willing to pick crops, work construction, and provide long-term care for baby-boomers.

Canada’s population also is aging, and Canada  is welcoming them l –part of that  country’s embrace of multiculturalism. We are not. Are we missing something?

All in all, this crisis is far more complicated than most reports acknowledge.

Before you decide where you stand on the issue, you might want to consider the media myths vs. the facts below.

                                        On President Obama’s Role

Fiction:  President Obama’s lax immigration policies have encouraged children to stream into this country.

Fact: As marauding gangs have taken over cities in Honduras, El Salvador and Guatemala, children have been fleeing, not only to the U.S. , but to Nicaragua, Panama, Mexico, Cost Rica and Belize.

 From 2008 to 2013, the UN High Commission on Refugees (UNHCR) has documented a 712% increase in the number of Central Americans applying for asylum in those five countries.

Clearly President Obama’s policies on immigration did not drive their decision to seek safe haven in Panama or Costa Rica.

Fiction: Reports of violence in Central America have been greatly overblown. These children are coming to the U.S. in search of jobs, social services and better living conditions.

Fact: Street gangs in Honduras, Guatemala and El Salvador torture and execute young boys who refuse to join. As I explained in part 1 of this post gang members also pick out young girls who they want to be their “girl-friends”—which means they will be raped by one or more members of the gang. Neither their families nor the police can protect them. This is why they run.

According to the U.S. State Department, Guatemala now has one of the highest violent crime rates in Latin America. El Salvador reports the second-highest murder rate in Latin America, and Honduras ranks #1, world-wide.

There, child murders are up 77% from just a year ago.

Finally, note that Nicaragua, which is the poorest nation in mainland Latin America (and the second poorest in the Western Hemisphere, after Haiti)  has seen a 238% increase in asylum applications from Central Americans in the last year. This serves as strong evidence that desperate children and families are not seeking “economic opportunities.”

There are no opportunities in Nicaragua. They are fleeing the mayhem at home.

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