Texting to Promote Weight Loss and in Population Health Management

Anyone who regularly attends a house of worship is certainly aware of how preachers make a point of regularly visiting parishioners while they're in a hospital. Since the Disease Management Care Blog's recent hospitalization involved an inconvenient distance (hour and a half drive) and time (6:30 AM), the DMCB pastor adapted by texting a prayer message. The DMCB took some comfort in what its colleagues euphemistically refer to as "faith healing."

Which is one reason why the DMCB paid attention to this interesting peer-reviewed abstract. 170 obese persons were randomly assigned to either monthly emails or daily "personally relevant and interactive" text messages. There was no difference in weight loss at 6 and 12 months of follow-up, but persons who were "adherent" to the text messages had statistically significant greater weight loss and greater activity levels.  Satisfaction levels were also high in the text message group.

And then there's this other study that randomly assigned obese college students to text messaging plus Facebook, Facebook alone and a "waiting list" control group.  In the limited follow-up of 8 weeks, the text messaging group lost a significantly greater amount of weight (2.4 kg.) vs. the other two groups.

Is texting an option for weight loss in particular and for population health management (PHM) in general?  These two studies would indicate the answer for both is "perhaps."  A better answer may be that texting plus other PHM interventions is better and that texting for persons who prefer it is best. 

The DMCB's Fat Lady might also approve of texting. If it's good enough for the prayerful among us, who can argue against it?

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State of the Art Obesity Management - Keep It Away from Primary Care

In the course of the Population Health Blog's last primary care encounter, a measurement of its height and weight determined that it was overweight.  On the way to the examination room, the nurse apologetically provided a patient education leaflet. The physician let the topic go unmentioned.

These health care professionals clearly were not "into" managing weight issues in their patient population.

After reading this paper, who can blame them?  A review of fifteen randomized clinical trials involving over 4500 patients showed that while primary care-based "behavior change for weight loss" results in statistically significant weight loss, the average amount was a clinically insignificant 3 lbs.

While web sites such as this provide useful pointers on engaging patients on the topic of weight loss, the U.S. Preventive Services Task Force (PSPSTF) recommends that persons with obesity be referred to a care setting that specializes in intensive multi-component behavioral interventions.

The primary care PHB agrees: these frontline clinics can screen for obesity using height and weight, but that's where their responsibility arguably ends.  Until there is research that shows otherwise, the primary care setting is no place for management of weight issues.

The PHB's care was state-of-the-art.

Is One DIet Program Better Than Another for Weight Loss?

As a doctor, the Population Health Blog was often asked by overnourished patients to help find a "best" diet.  Its advice to simply eat less and skip desert, however, was insufficient to overcome the commercial programs' allure of word-of-mouth, dubious advertising and fanciful on-line marketing . As a result, many desperate PHB patients fell into closed loops of pseudoscience, anecdotal testimonials and expertly crafted statements "not evaluated by the FDA."

As a population-health skeptic, the outcomes-focused PHB was never convinced that one commercial diet plan was "better" than any other.  Not only are excess calories very efficiently turned into corpulence by a very efficient human metabolism, it didn't make sense that that persons could eat their way to weight loss with more [insert one of the following: protein, fat, fiber, pre-packaged meals or vitamins].  Last but not least, if all these commercial weight loss outfits spent a tenth of their marketing budget on real science, the PHB may have had the evidence it needed to make a recommendation.

Well, a meta-analysis of "Named" (you'd recognize the brands) diet program outcomes has been published in JAMA and the results are decidedly unimpressive.  The good news is that all of the household-name programs result in modest weight loss compared to no diet.  The bad news is that the loss of two to six pounds for each program was no better or worse compared to the others.

The PHB's take?  It's up to the consumer to weigh their personal preferences for one type of diet plan vs. another.  In addition, out-of-pocket costs may also play a role in helping sustain the dieter's motivation in getting their money' worth. 

Beyond those two considerations, however, it's just a matter of eating less calories, not more of the latest nutritional fad.

Time for Docs to Get Out of the Food Wars

In Food Fad Fantasyland, rotund patients can see their primary care physicians and discuss the merits of Atkins versus South Beach vs. [insert name here].  Armed with the latest nostrums, patients go forth and diet until the next twerk comes along.

Bleh.

While physicians and the for-profit care management vendors can disagree about many things, one thing they can agree on is the ability of their corpulent patients to swear by an endless number of diets.  Whether its "low carbs" or "Mediterranean" or "mini-fasts," docs and coaches alike are expected to not only endorse these fads, but deploy insider jargon like DMCB spawn watching the MTV Video Music Awards. Taylor Swift was crooning about... who?

Which is why, after reading this JAMA Viewpoint article, the Disease Management Care Blog agrees that it's time call a time-out.  It's also time for the DMCB primary care colleagues to exit.

The DMCB explains.

Drs. Pagoto and Appelhans point out that when it comes to weight loss and risk factor reduction, there is no research that convincingly proves that one dietary approach is superior to any other.  Outside of individual preference, the mix of nutrients makes no real difference.  Instead, say the authors, what's important is adherence.  In other words, once patients embark on their preferred diet, they have to stick to it.

Unfortunately, that message has been lost in the multi-billion dollar faddism that has come to dominate the food industry marketplace.

Skeptics will point out that getting persons to stick to a particular diet is a fool's errand.

Not so, say the JAMA authors. Pointing to the Finnish Diabetes Prevention Study, The Da Qing Diabetes Prevention Study and the Diabetes Prevention Program, they note that long-term behavior change that includes behavioral modification and lifestyle change is very possible. 

"Hear hear!" says the DMCB.

As most doctors are aware, most health insurers (including Medicare) don't really reimburse enough to meaningfully cover the true costs of life-style related counseling.  What's more, selective memory recall means that physicians generally remember just how often their counseling leads to their individual patients being as fat as ever.  Most of us physicians are not that good at coaching anyway.

Which is why the DMCB thinks dietary counseling should be outsourced outside of the doctors' offices.  The good news is that wellness and health promotion programs are becoming more adept at focusing on patients' adherence to lifestyle change, mostly by finding those with a willingness to change. It's then a matter supporting those individuals over the course of a year or more. 

This is just one example of the approach.  There are more to come.

The DMCB conclusion

1. Docs should be "agnostic" when it comes to one diet fad vs. another.  It's patient preference.  Next.

2. What really counts is adherence to long-term lifestyle change.  Since many physicians are not good at that kind of long-term coaching, better to let other programs offer their wares to insurers.  The key for these programs is to focus on lifestyle change for those patients who want it and can accomplish it.

More on the Parallels Between the Sugary Beverage Ban and the Accountability Movement in Health Care

Time for some DMCB humble pie.

Check out Troeltsch's perspicacious response to the Disease Management Care Blog assertion in yesterday's posting that a New York City ban on the sale of 16 oz. calorie dense beverages would "work":

What evidence do you have for the comment "it works?" particularly in light of the fact that soda is simply banned in restaurants, and not any where else in the city?

Troeltsch has both right. 

The proposal, as it now stands, would limit the ban to restaurants, street vendors and concession stands and spares grocery stores. So while New Yorkers couldn't buy that "Big Gulp" to-go, they'd still be able to buy that liter of fructose corn syrup-loaded soda and continue their gluttonous ways in the privacy of their own homes.

And what's more, the DMCB did a literature search and can find no published evidence that a calorie-dense beverage ban reduces the prevalence of obesity. Yesterday's claim that "it works" was simply overzealous. DMCB readers can not only spot non-scientific puffery at meetings, in news reports and in marketing materials, but also in the DMCB's weaker-moment writings.

Well done.

That being said, the DMCB still gives the Big Apple some credit. If you go to the original proposal, you'll see that the ban is only one of 26 initiatives that seek to improve nutrition and increase exercise in the city's public schools, alter sidewalk and building codes to promote physical activity, require hospitals to offer healthy menus, increase the availability and appeal of tap water and promote wellness, especially among public employees. This is commercial population health management writ large.

And the DMCB still stands by its original assertions. Mayor Bloomberg's attack on obesity in the name of public health should remind health care providers that a similar fate awaits their costly ways if shared savings, accountability, bundling, electronic records, the demos and ACOs fail to bend the curve. Instead of trimming excess calories, our politicians will trim excess costs by proclamation.

The DMCB offers three additional observations:

1) Peter Orzag, one of Mr. Obama's health reform architects, famously asserted that the Affordable Care Act's health mandate provision would increase a collective expectation that we should all buy health insurance, much like seat belt laws prompted most of us to buckle up. There may be something to that in the anti-obesity fight, says the DMCB, and Mayor Bloomberg's very public attack on sugary drinks may prompt his city to shift to a new cultural norm

2) The DMCB hopes NYC's Department of Health and Mental Hygiene devotes the resources it takes to adequately measure the impact of the ban. The rest of the country needs to know if this works.

3) Last but not least, if nothing comes of this, this is one more warning to a largely uncooperative and unrepentant food industry.

Parallels Between the Sugary Beverage Ban and the Accountability Movement in Health Care

If New York City's Mayor Michael Bloomberg has his anti-obesity way, the Big Apple will begin banning the restaurant and concession sale of sugary beverages that exceed a volume 16 fluid ounces as early as March of 2015.  The Disease Management Care Blog suspects there is one big reason why Hizonner is deploying brute force in this battle of the bulge, this confrontation of the calories, this attack on adiposity:

It works.

Contrast the approach of simply outlawing obesogenic drinks with kinder and gentler approaches, like those based on education (food labeling and warnings), economic incentives (fat taxes), appeals to self-interest ("you'll look and feel better!") or enculturation (starting with food choices in our schools' cafeterias).  They all have their role, but let's face it: we don't heed labels, hate taxes, find life-style changes difficult, are suckers for the food industry's marketing and ultimately like the taste rush of corn syrup.  Take a stroll through Manhattan and it's pretty obvious we have a problem.

The Big Apple is doing this for our own public health good.

This lesson prompts the Disease Management Care Blog to ponder the largest threat to the success of the "accountability" movement in health care.  By "aligning" economic interests, offering savings-based "gain-sharing," leveraging decision support and enculturating physicians into "systems" of care imbued with best practices championed by physician leadership, we believe our collective taste for high cost testing, technology and pharmaceuticals will fade faster than the flab on The Biggest Loser.

Is that so?  Maybe not, and so the DMCB offers up two observations:

1. Assuming physicians are people and patients have their self-interest at heart, the likelihood that our appetitite for over-testing, the latest tech and brand name drugs will be blunted by electronic health record decision-support warnings, the promise of some savings-based future bonus, appeals at staff meetings to do the right thing or an expectation that physician culture will change is about as realistic as a successful John Edwards White House run in 2016.

2. And assuming that none of that works, the likelihood that future local and national politicians will use the same public health logic and announce a Bloomberg-esque "ban" of some high cost low value tests, technology and drugs is almost certain.

You read it here first.

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Obesity Surgery in Diabetes Mellitus: A Three Year Trial Shows High "Cure Rates." The Implications for Population Health

In case there is any doubt about the long-term efficacy of obesity surgery for diabetes, check out this three year study that was just published by the New England Journal of Medicine. 150 persons between the ages of 20 and 60 years with an A1c greater than the recommended target of 7% and a BMI greater than 27 were randomly assigned to either gastric bypass, sleeve gastrectomy or intensive medical therapy. 8 persons dropped out after being assigned to medical therapy and one patient had their surgery cancelled. Over the next 3 years, 4 persons were lost to follow up.

Of the remaining participants, two thirds were women and three quarters were white. The mean age was 48 years, the average BMI was a prodigious 36 and the mean A1c was a poor 9.3%, with an average duration of diabetes of just over 8 years. 

Of the 40 medical patients, 5% ended up with an A1c of 6%, versus 38% of the 48 bypass and 24% of the 49 sleeve patients.  The average weight loss was 4.3 kg in the medical patients vs. 26 and 21 kg in the bypass and sleeve patients. While only 2% of medically treated patients were able to stop their diabetes medications, 69% and 43% of the bypass and sleeve patients were able to do so. Only four patients in the surgery groups required additional surgery for the treatment of complications.  None died.

The Population Health Blog finds the results compelling enough to believe that the surgical option for obesity-related diabetes mellitus may be turning out to be a first line option.  The complication rate is acceptably low and the "cure" rate of up to 70% (if defined as not having to take medications) is likely to be welcomed by patients facing a lifetime of otherwise chronic illness.

Criticisms?

Critics may worry that any long-term economic benefits at a population-based level may be cancelled by the cost of surgery.  The PHB understands that, but doesn't believe that obesity surgery should be viewed through a "return-on-investment" lens.  Rather, the value assessment of "outcome" (in terms of diabetes and obesity cure) per unit of cost (dollars spent) is a as good as an investment compared to, say, coronary artery bypass grafting or a knee replacement.

Critics may also worry that obesity surgery is more of a symptom of an overfed society and that our national treasure would be better spent on understanding our dietary dysfunctions.  The Population Health Blog cannot disagree, but doubts that our national health spending can be wired so that every dollar spent on the promotion of nutritional wisdom will reduce the near-term health care cost crisis from diabetes.  We need to be prepared to invest in both.

Implications for Population Health

It appears to the PHB that this was a single site "efficacy" study involving an academic medical center.  We don't know if the low complication rate observed here is typical of other hospitals that offer obesity surgery.  In addition, this study did not examine the impact of the more popular approach of banding surgery.  That being said, this three year trial suggests that bariatric surgery should be offered in the suite of options for persons meeting the criteria above.

The good news is that shared decision making has already been evaluated in this setting.  While the majority of participants are more likely to chose conservative treatment, the point is that a 40-70% chance of cure over three years should be raised in the course of patient-centric coaching.  Population health vendors in the diabetes-obesity "space" should be prepared to engage patients on this treatment option and help them decide if surgery is the right choice for them.

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Qnexa for Obesity: Should It Ever Be Prescribed Without Concurrent Lifestyle Counseling? The Role of Disease and Population Health Management

Physician waiting room chair
for Qnexa candidates?

It's that time of year again. A political as well as cinematic blur of uninspiring candidates are being manipulated by an opaque, unaccountable and moneyed white male nomenklatura that foists "winners" on an unsuspecting public. The Oscars, the primary election year.... what's the difference?

So the Disease Management Care Blog distracted itself by turning its bloggy eye to newsmaker "Qnexa." This is a combination of two well known appetite suppressant drugs, phentermine and topiramate, that was just reviewed by an FDA expert panel. Their 20-2 vote in favor of approval makes it likely the Qnexa will be released to the market for the treatment of obesity sometime after a final Agency review in April.  Investors in Vivus like what it means for the company's prospects.

Population health management service providers should also like the prospects.

That's because Qnexa hasn't been tested as a stand-alone drug and, based on the published evidence, there is no evidence that it works without concurrent lifestyle counseling: 

The CONQUER Trial: "...assessed the efficacy and safety of two doses of phentermine plus topiramate controlled-release combination as an adjunct to diet and lifestyle modification for weight loss and metabolic risk reduction in individuals who were overweight and obese, with two or more risk factors."

The EQUIP Trial: "All patients were provided with standardized lifestyle counseling."

The SEQUEL Study: "All subjects participated in a lifestyle-modification program."

As the DMCB understands it, the FDA expert panel has recommended that Qnexa's release be tied to careful monitoring for an approximate 5% absolute risk of heart valve abnormalities. The DMCB believes they got it half right.

Access to Qnexa, based on the evidence, should also be explicitly tied to concurrent lifestyle counseling.  Assuming physicians are still unable to incorporate this into their usual clinic work flows, that leaves pharmacy benefit managers (who have supported patients with diabetes), patient centered medical homes and, last but not least, disease and population health management vendors.

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Governor Christie's Weight and How CNN Got It Terribly Wrong

Good for you, Guv!

In the course of its medical career, the Disease Management Care Blog has encountered a plethora of, um, let's refer to them as overnourished patients.  When the DMCB broached the issue, it typically confirmed what the peer-reviewed literature has shown: a large majority already knew they were fat.

Unfortunately, the literature also suggests physicians could do a better job of increasing awareness and combating unrealistic "dream BMIs" with education about the benefit of a modest 5% weight loss in reducing the medical risks that come with Governor Christie-style big belly.

And speaking of the Guv.....

Almost 600 persons who follow the DMCB on Twitter already saw this typically contrarian and provocative tweet.....

Does N.J Gov Christie's #obesity ( http://politi.co/UXm4cT  ) doom him? "Attributable risk" may say odds are in his favor http://1.usa.gov/14RFeF6

... where it was pointed out that there is good science that shows that being big adds a significant but an absolutely small degree of mortality risk. 

In other words, the likelihood that an obese person is going to keel over in any given day is quite remote.

That inconvenient fact, however, didn't stop former White House Medical Unit Director and physician Connie Mariano from proclaiming lurid warnings to the TV watching public about Mr. Christie's looming mortality on CNN ("I'm worried about this man dying in office!"). 

Predictably, the Governor, already aware of his girth, pushed back. 

And who can blame him? While Mr. Christie obviously knows he's big, is in the public domain and hasn't been shy about discussing his size, he has a point. The lack of a doctor-patient relationship with Dr. Mariano means she doesn't have access to his full medical history.  Mr. Christie argues that, despite his weight, he's still relatively healthy, which is very possible.  As pointed out in the science-backed tweet above, the statistical likelihood - based on weight alone - that New Jersey's Chief Executive is going to die anytime soon is quite small.

Dr. Mariano's factual ignorance is one thing, but enabling the CNN's unwitting paternalistic stigmatizing ("attempted to give himself a clean bill of health") of obese Americans is another. While physician attention to fatness is important, there is no shortage of good physician guidelines on how to broach the topic, provide a supportive environment and offer helpful counseling. While the DMCB thankfully didn't detect any overt "fatsim" in the talking-head doctor's commentary, it's no secret that negative stereotyping among physicians is all too common.

While even White House physicians can be forgiven for their naivete, the DMCB thinks our national media should be more responsible.  To those patients who watch CNN and rely on it for information about obesity, the DMCB suggests you may want to use your remote and punish news outlets when they descend into spectacles like this. 

We deserve better.

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