Obesity Reduced by Lifestyle Intervention

Today’s Managing Health Care Costs Indicator is 38.2%

Obesity isn’t easy to treat.

We all know that even people who reduce their caloric intake by 30,000 calories often don’t lose 10 pounds, and recent research shows that hormonal changes subvert our efforts to become svelte (or even to become non-obese). 

Two studies published in the Thanksgiving New England Journal of Medicine show surprising efficacy of lifestyle coaching to help patients lose weight.  In both studies the interventions were built around the primary care practice (not the insurance company), and both studies were part of an ambitious 24-month three center study funded by the National Heart Lung and Blood Institute. 

The NEJM published the Johns Hopkins study, done in collaboration with Healthways.  This study showed losses of 0.8kg (control group), 4.6kg (telephonic coaching only), and 5.1kg (in-person coaching).  A striking 38.2% of people in the telephonic coaching group lost more than 5% of body weight.  That number was 41.4% in the in-person group, even though participants only attended a small fraction of the recommended in-person sessions. Persistance with the web portal was also high.

NEJM also published the University of Pennsylvania study, which compared usual care with brief and enhanced brief lifestyle coaching.  Enhanced included treatment with medications and free provided low calorie meals.  The UPenn study showed weight loss of 1.7kg (usual care), 2.9 kg (brief coaching), and 4.6kg (enhanced coaching).  Again, a striking portion of the participants lost more than 5% of their body weight (usual 21.5%, brief 26%, enhanced 34.9%).

These are impressive studies.  They were difficult to carry out, although they were well funded.  Both studies had low dropout rates.  It will be important that the researchers also publish the results of the third study – to see if the results are consistent.   Even so, this reporting is much less subject to publication bias than most of what we see in the wellness literature.   The studies are also small – only about 400 people in each three-arm study, so under 150 in each of the treatment groups.  It’s also striking that the participants in usual care lost so much weight, since this is quite contrary to the usual practice experience.

Obesity is clearly one of the major causes of future preventable death and adverse health care outcomes – and it’s heartening to see credible evidence of efficacy of the coaching intervention.

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Curing Obesity Won’t Solve the Health Care Cost Crisis

Today’s Managing Health Care Costs Indicator is $7 billion

Kenneth Thorpe has a cheery simulation in this month’s Health Affairs postulating  that if we enroll 2.6 million Americans aged 60-64 in a nutrition training program (run by the YMCA) we could save $7 billion over their lifetimes.

The simulation is based on the National Diabetes Prevention Program.,  a huge well-designed study that resulted in 7% body weight loss sustained over 2.8 years of followup and reduced the prevalence of diabetes among the participants from 58% (and by 71% in those over 60).   The intervention cost $1340 per person

Be sure to read the fine print. 

•       This is based on a study done on 92 participants in the YMCA program, published in the American Journal of Preventive Medicine.
•       The savings are available over the beneficiaries’ lifetimes –which makes it hard to imagine what the denominator is, since we don't usually think of the average liability for a person’s Medicare costs at the moment she turns 65.
•        The intervention in the NDPP cost $1340 per person and involved individual training, while the intervention at the YMCAs cost $240 per person and used classroom education, which a smaller number of sessions.
•       The simulation assumes that this intervention could be scaled from 92 people to 2.6 million enrollees
•       The $7 billion assumes 70% of those who are eligible (at risk for diabetes) enroll.  Enrolling this many people in a program would be a staggering feat.  Weight Watchers enrolls 1.2 million members, and has 56,000 employees.

Here’s the real kicker.  If we accept all of these assumptions, believe that the very small YMCA trial is adequate proof of concept, and enroll overweight people at risk for both diabetes and heart disease, this program would save $3.7 billion over 10 years, or $370 million per year.  Medicare will spend $569 billion in 2012.

That means that this intervention would shave 0.06% off of total Medicare spending.

This program is probably a very good idea – and keeping people from getting diabetes (or delaying onset) could clearly save money and make peoples’ lives better.  But let’s not congratulate ourselves for finding a solution to cost increases in Medicare without dealing with the tougher issues.

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Obesity: The Problem is Clearer than the Solution

Today’s Managing Health Care Costs Indicator is 42%

We all know America is getting more obese, and Ezra Klein had a post yesterday pointing out that while cigarettes kill, obesity often doesn’t kill –but causes disability, chronic disease, and expenses that are 42% higher than the nonobese.  

So – we could save a lot if obese people would lose a lot of weight.

However, moving from this conclusion to practical steps to skinny down the population isn’t easy.   It’s a challenge to figure out how to get people to lose weight. 

June’s Journal of Occupational and Environmental Medicine has a careful study from the Netherlands where construction workers at high risk for heart disease were randomized to either an intervention, an average of 5 visits with a health coach over 6 months, or a control group.   (Groeneveld, et al, JOEM 2011 53:610 .  I’ll post a link in the future – the article isn’t yet indexed in pubmed)

The good news – the construction workers lost weight.  On average, they lost 2 kg (4.4 lbs). 

The unsurprising bad news – the intervention wasn’t cheap, and the cost of the intervention group exceeded the cost for the control group. The cost for each pound of weight loss was 145 euros ($210). The cost over 12 months of the intervened workers, including all health care costs, work productivity, and any costs of lifestyle related expenses, was 254 euros more ($369) than the control group. 

There are a lot of programs out there promising to deliver lower weight and short-term decrease in health care costs.  Some of them give statistics on average weight loss of those who lost weight, utterly ignoring any participants who gain weight. Most assess weight loss over a very short period of time, ignoring the fact that many who initially lose weight gain it right back again.  Most programs impute savings based on the fact that skinnier people have lower health care costs.

However, those who were overweight don’t necessarily cost less immediately after successful weight loss.  Further, there are precious few programs that help patients lose weight and keep it off.  In fact, the evidence for bariatric surgery is good, and the evidence of sustained effectiveness for all other interventions is modest to nonexistent.  

Treating the obese is not the way to address this major public health and health care cost crisis. 

What we need is public health interventions to make it easier to exercise and easier to get filling, nutritious, and healthy food – even in the hurried lifestyle we lead.  Many efforts, like zoning laws to encourage dense housing in close proximity to public transit, could take more than a generation to bear fruit.   Bike lanes, bike racks, and walking paths can take years to plan and build.   Other initiatives, like posting of calories, or employers offering healthy frozen dinners to take home,  could have an impact much sooner. 

None of these interventions will save health care dollars today - they can decrease obesity and prevent health care expenses much later.   

Preventing obesity won’t be easy – but it’s more likely to be successful and affordable than merely treating those who are already obese.

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Block That Metaphor – and Marbled Fat

Yesterday on Fresh Air Maggie Mahar told Terri Gross of NPR that there was 30% waste in the health care system. She went on to say that the waste was not just “fat hanging out of the sides of the meat…. It is marbled in, so we’ll need a scalpel” to remove the waste.

I don’t know any carnivorous surgeons who can use a scalpel to carve out marbled fat. While at first I thought the metaphor was awful – perhaps it’s very apt. Cutting out some waste might appear easy – but since waste is always someone’s income, removing it might be akin to removing the marbled fat in a steak.

Speaking of marbled fat- Health Affairs had a timely web release yesterday pointing out the cost of obesity n the American health care budget. This article assigned $147 billion to excess costs from obesity in 2006 – and pointed out that obese people cost 13% more than matched nonobese people in the working population under 65 (with private insurance).

This number will be quoted a lot – and it should be. We pay a huge societal price for being sedentary and eating too many calories. Individuals with high BMIs(body mass index) pay a high personal price, too.

Let’s remember, though, that identifying obesity as a cause of excess costs is not equivalent to solving the health care cost crisis. In the medical world, there aren’t many wildly successful approaches to weight loss aside from bariatric surgery – which is serious enough that it is restricted to those with morbid (severe) obesity. There are things we can do outside of the medical world – like building bike lanes and walkable cities, opening up the stairway doors and discouraging elevator use, and putting calorie counts on menus. None of these has been definitely proven to cause weight loss – but at least all of these public-health oriented measures are inexpensive. They are also a great example of “choice architecture,” making it easy for people to make more personally and socially beneficial choices.

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