Managing Managed Care

Our inequitable, inefficient, oftentimes uncaring health care "system," revealed. -- Jeffrey G. Kaplan, M.D., M.S.

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Obesity; Soon More Manageable, But Not By Pills Like Thyroid Conditions

"We are not an overweight-obese nation just because we drink sugary beverages. We are obese and overweight from self-medicating with sugar, starch, alcohol, tobacco and other forms of serotonin increasing, anxiety decreasing substances because we live in a psychological culture that deprives us of essential social nutrients such as respect, dignity, being listened to and valued as human beings."

ref.: Donadio G.[the author of "Changing Behavior" and "Banning Supersize Sodas Isn’t the Answer"]

Stress and Sugar Indulgences
  • This is the first study to show that consumption of sugar but not artificial sweetener inhibits stress-induced cortisol secretion. 
  • Also, consumption of sugar inhibited the usual stress-induced decrease in activity in the hippocampus and increased opioid tone in the brain.
  • It seems that there is a negative feedback pathway that is affected by sugar.
  • This may make explain why many persons are more likely to use sugar-containing foods and beverages when under stress.
  • Knowing the strong biological basis for the reinforcing effects of sugar consumed under stress can make us more empathetic towards our patients (and ourselves!).
  • Attempts to reduce excessive sugar consumption and obesity must include stress reduction and stress management strategies.

"Tryon et al. Excessive Sugar Consumption May Be a Difficult Habit to Break: A View From the Brain and Body." J Clin Endocrinol Metab. 2015 Jun;100(6):2239-47. PubMed PMID: 25879513.

As published in GME Research Review, a monthly newsletter edited by Rajnish Mago, MD, who is Associate Professor of Psychiatry at Thomas Jefferson University and is author of "The Latest Antidepressants and Side Effects of Psychiatric Medications: Prevention, Assessment, and Management." Dr. Mago selects, summarizes, and provides a clinical commentary on the latest published research in psychiatry.

With regard to: "How Do You Put a Nation on a Diet?"  (NY Times, pub. June 9, 2012), Phillip M. Boffey writes: "While obesity has often been seen as a personal failure, experts increasingly point to societal factors and the need for nationwide remedies."  Indeed, to effect any significant reduction in "obesity rates will require multiple strategies on a population-wide scale." Take no solace in that curbing smoking is less challenging. "But there isn’t any choice if we want to protect the public’s health, the strength of the economy and the government budget."

So, this is not only a health risk issue, it is a financial imperative—we must get adverse lifestyle choices like smoking, sedentary behavior (i.e., not exercising or being active), and/or eating too much under control. 

When you think of it, the only fair way to handle the shared costs of these health risks is on a community-wide basis, otherwise known as "community rated" (as opposed to "experience-rated") health care insurance.  In other words, what's it going to cost all of the rest of us who now share in the cost when a patient prefers to be habitually lazy, indulgent or otherwise just keeps hurting themselves?  When patients have a choice and fail to hold up to their responsibility, they are adding, unnecessarily, to the cost of care.  The natural consequence then is that we require them to have 'skin in the game'—the concept of personal accountability.  IOW, if you have health care coverage, entitlement or insurance, but you fail to attend to symptoms or signs, or you suffer the ill effects or risks of adverse lifestyle choices, there must be some (albeit limited so as not to be restrictive) financial consequences.

Caveat Emptor: The most repugnant ‘slippery slope,’ for insurers is the denial of care for pre-existing conditions—the insurance practice of "rescission" (df: the unmaking of a contract, using a preexisting condition such as cancer 20 or 20 years prior as an excuse to not pay for legitimate care).  Using insurance talk, we must not allow 'experience rating'; we must make every effort to preserve 'community rating.' If that requires a Mandate – so be it!

Promoting Health 101: How to get started with a weight loss program

First of all, standardized weight loss programs are more costly, yet only marginally more effective than customized ones

For instance, in one study of 363 adults (mostly women; mean age, 42; mean body-mass index, 33 kg/m2) received up to 42 group-based counseling sessions over 18 months that included improving physical activity and eating habits. Participants were randomized to either a standard behavioral weight loss intervention group (SBWI where they received the complete set of counseling sessions) or a stepped care (STEP where both the frequency and type of sessions were modified according to how the participants did attaining specific goals, reviewed every 3 months), however, STEP participants moved to the next set of counseling sessions only when the previous goal was not achieved.

Results: About 3/4 of each group completed the full 18-month program. The mean weight loss was 7.6 kg in the SBWI group and 6.2 kg in the STEP group (8.1% vs. 6.9%, a non-significant difference). The total cost was estimated to be about US$1350 for the SBWI and $780 for the STEP program.

Comment: "These approaches suffer from all the same problems as other behavioral approaches: a fairly modest weight loss for so much effort, a partial rebound in weight loss from the initial response (weight loss in both groups peaked at 6 months), and a significant drop-out rate. The wide variation in costs argues for an approach that focuses more energy on patients who are making less progress, rather than a one-size-fits-all approach."— Thomas L. Schwenk, MD  Journal Watch Gen. Med. July 5, 2012 [with reference to]

Jakicic JM, et al. "Effect of a stepped-care intervention approach on weight loss in adults: A randomized clinical trial." JAMA 2012 Jun 27; 307:2617. ( Medline abstract (Free)

Let’s Begin at the Beginning–Our Children Need to Get Moving!

A third of children in the United States are overweight or obese. This is an ominous trend; predictions are scary—42% of the population are predicted to be obese by 2050 and as a consequence, many of them may not outlive their parents.  It’s time to take note, if not panic.

Only a small proportion of obese or overweight kids will have a medical cause such as Cushing’s disease, an underactive thyroid gland, or a genetic condition like Prader-Willi syndrome.  The rest, the vast majority are simply eating more calories than they are burning. Beware the so-called “obesogenic environment” in which we live – energy-dense foods are freely available and being active is no longer a fundamental part of our day to day life. 

But let us not despair—Being or becoming overweight or obese is not inevitable. Frankly, it’s a matter of the lifestyle choices that we make, which directly or indirectly influence our children making the vital difference between children and teens following a healthy pattern of weight gain or setting them off on a dangerous journey towards obesity and ill health.

The benefits of exercise during childhood

Aside from preenting excessive weight gain, taking part in regular physical activity while children are growing up can convey a range of benefits for health. For instance, exercise helps to ensure that their musculoskeletal system develops as it should. Weight-bearing exercise such as walking, skipping and running increases bone mineral density and that helps guard against osteoporosis that appears later in life.  [This subject is reviewed by Gunter, Almstedt and Janz (2012)—see below.] In young children exercise also improves coordination—essential for tasks of daily living. Their cardiovascular system also benefits; with regular exercise, blood pressure and cholesterol.  The improved cardiovascular risk profile, if carried into adulthood can lower the risk of heart disease and stroke. [This  is discussed further in a review by Brambilla, Pozzobon and Pietrobelli (2011).]

Lung function is superior in children who exercise and this can even help in asthma management.  [See Nixon (1996).] But, it isn’t just physical health that improves with activity, mental wellbeing also benefits as is highlighted in the reference, below by Floriani and Kennedy (2008). We also note that the incidence of stress, low mood and anxiety is more common in children today, but being more active can help in all these areas, as well.  At the same time, confidence and social interaction improves in children who are more active and who have more initiative. Furthermore, many of these improvements can help one avoid the need for children to take prescription medications, which something concerning these days.

Physical activity recommendations

The recommendations for physical activity are far from being met; the 2011 National Youth Risk Behavior Survey* revealed that just less than 29% of those children questioned had undertaken the recommended hour of daily activity during the previous week.  [Ref. Guidelines set by the Federal Government in 1998 for children aged between six and seventeen.] The majority of this exercise should be aerobic and on at least three days of the week this should be fairly vigorous, for example jogging or running. Activities that aid muscle strengthening such as use of a climbing frame in younger children or gymnastics should also feature three times weekly. As mentioned previously, bone strengthening exercise is important and again should be included on three or more days each week. The 60 minutes of activity does not have to be undertaken all at once and an activity may encompass two or more of the three types of activity mentioned here.  We note that exercise does not have to be structured, so a game of tag or an afternoon spent climbing trees can offer similar value to a session of swimming or a game of a team sport.

Knowing what our children should be doing obviously isn’t enough; how can these recommendations be translated into action?

* CDC.Gov/healthyyouth link failed 2/19/2017


Brambilla, P., Pozzobon, G. & Pietrobelli, A. (2011) Physical activity as the main therapeutic tool for metabolic syndrome in childhood. International Journal of Obesity, 35 (1):16-28.

Floriani, V. & Kennedy, C. (2008) Promotion of physical activity in children. Current Opinion in Paediatrics, 20 (1):90-5.

Gunter, K.B., Almstedt, H.C. & Janz, K.F. (2012) Physical activity in childhood may be key to optimizing lifespan skeletal health. Exercise and Sport Science Review, 40 (1):13-21.

Nixon, P.A. (1996) Role of exercise in the evaluation and management of pulmonary disease in children and Youth. Medicine and Science in Sports and Exercise, 28 (4):414-20.

Additional diet plans, reviewed:

"There is good evidence indicating that although obesity may start as a lifestyle-driven problem, it can rapidly lead to disturbed energy-balance regulation as a result of impaired hypothalamic signaling, which leads to a higher body-weight set point.5 Thus, obesity may be considered a disease initiated by a complex interaction of genetics and the environment....The management of obesity is difficult. Emerging evidence suggests that bariatric surgery may establish a new body-weight set point by altering the physiological mechanisms of body-weight regulation, thereby causing sustained weight loss....However, [long-term (>10-year) follow-up will be necessary to track the persistence of the associated micronutrient deficiencies, as well as the emergence of other deficiencies and other unanticipated long-term complications. Only then will providers be fully informed for the counseling of adolescents and their families with regard to the benefits, risks, and timing of bariatric surgery."

Apovian CM. "The Obesity Epidemic — Understanding the Disease and the Treatment." N Engl J Med 2016; 374:177-179A concise review on the therapeutics of obesity." Nutrition Oct. 2000;16(10):953-960

My point? -- All these pale in steadfast lifestyle management, i.e., comparison to diet and exercise!

See also, 

Tuesday, December 14th, 2010

"In their quest to find drugs to curb obesity, scientists have had about as much success as long-term dieters who want to stay thin — which is to say, very little. In fact, the last year has been so bleak on the research front that some experts are questioning whether a long-desired safe and effective diet pill can be found.

Advisory panels for the Food and Drug Administration has been recommending against approval experimental weight-loss drugs citing unacceptable risks (e.g., heart attacks and strokes) or unimpressive benefits.

Beyond diet and exercise (i.e., self-control), will there ever be a cure for obesity?

"If you double one percent seven more times.... you get 100 percent.

"We have exactly doubled the amount of the genetic data collected each year since 1990, and this pace has continued since the completion of the Human Genome Project in 2003. The cost of sequencing a base pair of DNA -- the building blocks of our genes -- has dropped by half each year from $10 per base pair in 1990 to a small fraction of a penny today. Deciphering the first human genome cost a billion dollars. Today, anyone can have it done for $350,000. But, in case that's still out of your budget, just be patient for a little while longer. We are now only a few years away from a $1,000 human genome. Almost every other aspect of our ability to understand biology in information terms is similarly doubling every year."

[With regards to the management of obesity, what's my point?]

"Our genes are essentially little software programs, and they evolved when conditions were very different than they are today. Take, for example, the fat insulin receptor gene, which essentially says 'hold on to every calorie because the next hunting season may not work out so well.' That gene made a lot of sense tens of thousands of years ago, at a time when food was almost always in short supply and there were no refrigerators. In those days, famines were common and starvation was a real possibility, so it was a good idea to store as many as possible of the calories you could find in your body's fat cells.

[However,] "Today, the fat insulin receptor gene underlies an epidemic of weight prob­lems, with two of three American adults now overweight and one in three obese. What would happen if we suddenly turned off this gene in the fat cells? Scientists actually performed this experiment on mice at the Joslin Diabetes Center. The animals whose fat insulin receptor gene was turned off ate as much as they wanted yet remained slim. And it wasn't an unhealthy slimness. They didn't get diabetes or heart disease, and they lived and remained healthy about 20 percent longer than the control mice, which still had their fat insulin receptor gene working. The experimental mice experienced the health benefits of caloric restriction -- the only laboratory-proven method of life extension -- while doing just the opposite and eating as much as they wanted. Several pharmaceutical companies are now rushing to bring these concepts to the human market."

Ray Kurzweil and Terry Grossman, MD  "Transcend: Nine Steps to Living Well Forever." Pub.: Rodale Inc. 2009  pp: xiii-xvi

Addendum–We mentioned thyroid in this discussion. Please see: Thyroid Awareness

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