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medpundit |
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Friday, May 30, 2003For an example, just check out the comments section of my TechCentral column. There’s many a reference to laziness and the idea that fat people should be taxed. I’ve also been more aware recently of an overt prejudice against the obese among my professional colleagues. I’ve had overweight and obese patients tell me stories that make me ashamed of my profession. One woman went to an orthopedist for painful degenerative arthritis in her knee. He didn’t do anything for her but tell her she had a problem because she was fat. As she put it, “Duh!” But here’s the shameful thing - he would have given anyone else a steroid injection to reduce the inflammation and allow them more mobility. He just told her to lose weight. And she paid him over $200 for the insult. Now, she’s going to find it all the harder to initiate that exercise program she wants to do because her knee still hurts. Then, there was my patient who was hospitalized for chest pain. Before finding out the cause of her chest pain, the cardiologist told her walking around with her body would be the equivalent of his walking around with his wife and child strapped to him all day. She already knows that. Here’s what he doesn’t know - she’s living an unhappy life in a miserable marriage which she can’t leave for a myriad of reasons. Her eating disorder and lack of exercise is a lot more complex than he was willing to consider. And his comment only served to add to her unhappiness. Far from being a motivation, it was just one more blow to her will to help herself. Underlying all this anger is the assumption that fat people are a greater drain on the healthcare system’s resources than skinny people. There isn’t any concrete evidence that this is true. There are many obese people who have no health problems at all. There are also many skinny people who have diabetes, arthritis, and heart problems. There’s absolutely no evidence that fat people go to the doctor more often than skinny people. In fact, they may go to the doctor less often. Who wants to sit naked in front of someone who in the end will just harangue you about your weight? Obesity and weight gain are a complex issue. Some of us have high resting metabolic rates and can eat more and exercise less without gaining weight than others with lower resting metabolic rates. And substantial weight gain can come from the slightest alteration in our energy balance. It can be from a slowing of our resting metabolic rates due to drugs or aging or disease. Or it can be from just a very small increased caloric intake over a period of years. Or it can be from declining physical activity due to age and disease. Is it really reasonable to harangue a 70 year old with arthiritis and hypothyroidism into starving herself and exercising everyday for an hour so she can attain a “normal” BMI? Is it reasonable to expect the 38 year old father of four to give up 45 minutes of the few hours he has in the evening to spend with his children for the treadmill or gym? I’m beginning to wonder. Maybe we should all lighten up. And I don’t mean physically. UPDATE: A reader emails: You are incorrect. There is a small but growing body of research that shows (consistently) that obese people incur larger health care costs, on average, than non-obese people. A couple of weeks ago a study by economist Eric Finkelstein, published in the respected journal Health Affairs showed this (see here for the press release and here for the study and here for a sample of news coverage). Moreover, Finkelstein found that much of the cost is borne by Medicare, Medicaid, and other government programs (i.e., the taxpayer). Earlier research by Roland Sturm of RAND and several other researchers have come to essentially the same conclusion. Obviously, not all obese people have high health care costs, but referring to the population as a whole, obesity clearly is associated with increased health care use and costs. The magnitude of the cost is similar to that of smoking, according to Finkelstein. I think you should retract your erroneous claim. Whenever the word “respected” is used to strengthen an argument, proceed with caution. The New York Times is a “respected” newspaper, yet only a fool would believe everything it prints. The New England Journal of Medicine is a respected medical journal, yet it often publishes studies in which authors make dubious claims based on their data. So it is with this study, which can be summed up in three words: estimate, estimate, estimate: In this study we use a regression framework and nationally representative data for adults, including those over age sixty-five, to compute per capita and total medical spending attributable to overweight (body mass index [BMI] = 25.0– 29.9) and obesity (BMI ? 30). This approach allows us to assess the impact of overweight and obesity on select payers, including individuals, private insurers, Medicare, and Medicaid. ....The 1998 Medical Expenditure Panel Survey (MEPS ) and the 1996 and 1997 National Health Interview Surveys (NHIS) are the primary data sets used to develop spending estimates. MEPS is a nationally representative survey of the civilian noninstitutionalized population that quantifies people’s total annual medical spending (including insurance spending) and annual out-of-pocket spending....The data also include information about each person’s health insurance status and sociodemographic characteristics (such as race/ethnicity, sex, and education). The MEPS sampling frame is drawn from the 1996 and 1997 NHIS. Although MEPS does not capture height and weight (the determinants of BMI), these self-reported variables are available for a subset of adult NHIS participants and can be merged with the MEPS data For good measure, and because the spending reported by their first selection, MEPS, was considered too low by the authors, they introduced yet another set of data into the equation: For a variety of reasons, including the lack of data on institutionalized populations, MEPS spending estimates are much lower than comparable estimates from the National Health Accounts (NHA), which are generally considered the gold standard for annual health spending data in the United States. Therefore, we report overweight- and obesity-attributable spending estimates based on the 1998 NHA in addition to the MEPS estimates. To compute the NHA estimates, we multiply the percentage of total expenditures attributable to overweight and obesity estimated via MEPS by total expenditures for the corresponding insurance category reported in the 1998 NHA. Admittedly, I’m no statisitician, but there seems to be a lot wrong with this study. Mixing data from different years is one. Taking information from one set of people and applying it to a different set is another. Then, too, the authors don’t include the results of their analysis. They only present their conclusions from that analysis in table form. They would have a much stronger argument for the association of obesity and healthcare spending if they showed us their data, especially given the limitations of their methods: Multiple regression is a seductive technique: "plug in" as many predictor variables as you can think of and usually at least a few of them will come out significant. This is because one is capitalizing on chance when simply including as many variables as one can think of as predictors of some other variable of interest. They’ve left out a key component in their argument; one that’s necessary to know if their conclusions are to be taken seriously. Which only leaves one wondering what they’re hiding. Could it be that their numbers aren’t as supportive of their conclusions as the press release would have us believe? I stand by my original assertion. posted by Sydney on 5/30/2003 08:05:00 AM 0 comments 0 Comments: |
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