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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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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Polarized Politics Led To Cantor’s Defeat– and Cochran’s Victory. Why the “Uncommitted Center” Is So Important (Cantor part 2)

Please scroll down for Part 1 of this post. 

When House Majority leader Eric Cantor lost his seat to ultra-conservative David Brat, the Washington Post’s Ruth Marcus summed up the majority view among political pundits: “The episode offers a disturbing commentary about the poisonous, polarized state of American politics.”  

I cannot agree. I don’t think “polarization” is toxic.  To the contrary, as the poet William Blake once wrote “Without Contraries, No Progress.”  Conflict can clarify issues, and help us move forward.  Indeed, the clash of opinions is a time-honored way of testing their validity.

Do you remember the 1990s, a decade when it became difficult to tell the difference between Democrats and Republicans? While Republicans headed toward the far right, Democrats moved right of center. During his second term, Bill Clinton started to sound all too much like Ronald Reagan, as he set out to “reform welfare,” forcing single mothers to go to work, even though we weren’t offering them affordable day care. After leaving the White House, Clinton reclaimed his position as a stand-up liberal, but at the time, the distinction between Democrats and Republicans was badly blurred.

Today, the difference between the two parties is clear.  I wouldn’t say that Democrats are ultra-liberal, but conservatives have moved so far to the right that Democrats had no choice but to take a stand on critical issues including: global warming, gun control, the need to raise the minimum wage, and universal access to health care.

By contrast, in the 1990s, Congressional Democrats were “lukewarm” on health care reform. As  Paul Starr reports in his newest book, Remedy and Reaction, Senate Finance Committee chairman, Daniel Patrick Moynihan, Democrat of New York, actually stood up to say, “We don’t have a health care crisis.”

But by  2010,  the crisis was obvious, and Democrats came together. Pelosi and Harry Reid marshaled the votes, and Congress passed legislation which, while far from perfect, is solidly progressive: Low-income and middle-income Americans receive the subsidies they need; insurers can no longer discriminate against people suffering from pre-existing conditions, and preventive care–including contraception–is free.There is much more work to be done, but at last, we have begun.

Since then, Congressional Democrats have not had the votes to pass much-needed legislation in other areas.

But at least President Obama is no longer the compulsive compromiser that he appeared to be during his first term in office. I see this as progress.  As I have argued in the past, on some issues compromise is not an option.  Too much is at stake. 

On the ground,voters are as divided as their elected representatives.  Politically active Democrats have begun to move  left of center while Republican voters have become more conservative. The Pew Research report that I discussed in the first part of this post reveals that a decade ago, only 10% of politically engaged Republicans took a conservative stance on almost all issues. Today, 33% express consistently conservative views. At the other end of the political spectrum, almost forty  percent of committed Democrats are consistent liberals, up from just 8% in 1994. The overall share of Americans who express consistently conservative or constantly liberal opinions has doubled over the past two decades from 10% to 21%. .

“As a result,” Pew reports, “ideological overlap between the two parties has diminished. “Today, 92% of Republicans are to the right of the median Democrat, and 94% of Democrats are to the left of the median Republican.”. 

“Republicans and Democrats are more divided along ideological lines – and partisan antipathy is deeper and more extensive – than at any point in the last two decades. And a new survey of 10,000 adults nationwide finds that these divisions are greatest among those who are the most engaged and active in the political process.”

                                 Is Polarization A Threat to the Nation?

Most pundits are appalled.
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Cantor’s Defeat–Wittiest One-Liners

Eric Cantor’s shellacking has drawn much attention–perhaps two much commentary. (After all, this was just a primary.  I don’t think that it “Changes Everything.”)

That  said, here are my favorite comments on this event::

– “‘Brat Upsets Cantor’ . . . The headline sounds like a failed Bar Mitzvah” — Delaware Dem

On Tuesday night, Ezra Klein wrote:“John Boehner must be having an emotionally complicated evening.”

 

 

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