This morning I read an article in the NYT that actually made me feel sorry for health insurance companies and wonder just how affordable the Affordable Heath Care Act will be.  The article was entitled “Learning to be lean.  With few proven models, health sector takes on childhood obesity,” and was written by Reed Abelson.  Apparently, the new federal health care law, among its many provisions, requires both health insurers and employers to pay the cost of screening children for obesity and providing them with appropriate counseling.  This has health insurers scrambling to find what just what appropriate counseling might be.

I don’t need to remind any of my readers that childhood obesity is a big (no pun intended) problem; about 30% of children are considered overweight (the politically correct terms are “at risk for overweight” and “overweight.”  Please don’t ever call a child obese.  Anyway, there are considerable data in the scientific literature to show that childhood obesity is a risk factor for adult obesity and its many health problems.  So, screening for overweight or whatever we want to call it is appropriate as is conveying the information to parents.  This task is not terribly complicated or costly- just a quick height and weight measurement, calculation of a BMI, and information about what the data mean.  This information should be part of any well child medical care visit and the information can also be provided to parents through the schools, something already done in many places.  So far so good.  But what about “appropriate counseling” for those children found to be overweight?  As the NYT article notes, there are few if any proven models (how about no proven models with good long-term success?) to chart a way forward for insurers and employers.  So, is the U.S. health care system (to the extent we have a system) now taking the tack of requiring health insurers and employers to do the research and determine what constitutes appropriate counseling? It’s sort of like requiring insurers to screen for cancer and when a diagnosis is made, to do the research to find the most effective therapy.   In my opinion this is not health care reform at its best.  We should not identify health care problems such as childhood obesity and then require action that is very likely to be time and money poorly spent.  Good intentions do not justify unproven interventions.

I do not want to seem like a total grinch about this subject.  I like many provisions in the Affordable Health Care Act and I  would recommend that we screen children for weight status along with other health measures and require that health care providers offer nutritional counseling  (covered by the health insurer) on an annual basis, much like Medicare already does for people with diabetes mellitus.  That would be a reasonable start and one that might make the Affordable Health Care Act more affordable than the road we seem to be going down.  We must not outpace the science with our desire to do all that is possible in an effort to make our children healthy.

Like clockwork, every year, starting in early November and running well into the new year, newspapers and magazines are packed full of articles to warn us about the well-known holiday season weight gain and what to do about it.  This year was no exception.  In this entry, I want to highlight what I think were some of the most interesting articles.  I don’t need to remind you that we in the U.S. are, as a group, on the heavy side.  How did we get that way?  Many studies have documented our  slow but steady weight gain beginning in early adulthood, averaging about 2-2.5 lbs each year.  That doesn’t seem like a big deal, but you can do the math- 2 lbs/yr X 30 yr = overweight. Studies have also shown that most of the annual weight gain actually does take place in November and December.  So, can we do anything about holiday-induced “weight creep?”

The first article I recommend to you is entitled “the Fat Trap,” and was written by Tara Parker-Pope (NYT Magazine, Sunday January 1, 2012).  Ms. Parker-Pope bemoaned the fact that it is difficult to lose weight and summarized a study carried out by a group of European investigators (Sumithran P et. al.: Long-term persistence of hormonal adaptations to weight loss.  N Engl J Med 2011;365:1597-1604).  Fifty overweight people were put on a 10 week weight loss program.  The investigators measured a large number of hormones related to appetite at baseline, 10 weeks, and after 62 weeks.  They found that weight loss was associated with both increased appetite and increased levels of the appetite-stimulating hormones.  Unfortunately, most of the patients regained the weight they lost and still had increased appetite and increased levels of the appetite-stimulating hormones at 62 weeks.  The investigators concluded that mediators of appetite encourage weight gain.  Ms. Parker-Pope put it more bluntly: once we become fat, most of us despite our best efforts will probably stay fat.

The second article I recommend to you is entitled “New way calories can add up to weight gain,” written by Ron Winslow (Wall Street Journal Wednesday January 4, 2012).  Mr. Winslow summarized a study published that day in the Journal of the American Medical Association or JAMA (lead author George Bray from the Pennington Biomedical Research Center, Baton Rouge, LA).  The investigators fed 25 men and women about 1000 excess calories every day for 56 days but with diets that varied in the percentages of protein and fat  they contained (carbohydrates were about 40% of total calories for both diets.  The investigators found that although the subjects ingesting the low protein diet gained the least weight (about 7 lbs), they had as much gain in fat mass as the subjects on the normal and high-protein diets, whose excess weight gain was largely related to a gain in lean body mass.  The investigators concluded that “fad” diets with widely varying proportions of fats, carbohydrates, and fats, may not be the way to go in dieting, but rather, should focus on decreasing total calories and fat content.  In addition, the data showed that the BMI, a traditional way of assessing a patient for weight status, may not be very good at picking out those who have high body fat mass as opposed to high lean body mass.  As an aside, on the same page as the Bray study report, is a report by the same journalist, Ron Winslow,  on a Swedish study touting the health benefits of bariatric surgery for weight reduction (“Procedure’s benefits go beyond weight loss”).

The third article challenges Parker-Pope’s pessimistic view of weight reduction efforts.  It is entitled “Be it resolved,” and was written by John Tierney (NYT Sunday, January 8, 2012).  The article is all about the power of New Year’s resolutions to help people lose weight.  Tierney recently co-authored a book with Roy F. Baumeister entitled “Willpower: rediscovering the greatest human resource”.  I confess that I have not read the book, only the newpaper article.  Dr. Baumeister is a social psychologist at Florida State University.  The lengthy article presumably summarizes the book’s message: setting goals is most useful if the goals are accompanied by firm (written down) resolutions,  and that it is possible to reinforce one’s willpower; studies have shown that setting goals without concomitant resolutions, is far less likely to result in long-term successl.  I cannot say that I was much impressed with the recommendations other than that they are logical but  rather complicated,  and it is my guess that anyone willing to do all the things that are recommended to make the resolution work, doesn’t dare fail.  I can’t think of any good reasons not to try the resolution advice.

The last article also appeared in the Sunday January 8. 2012 issue of the NYT.  It was entitiled “Young, obese and in surgery: youth procedures rise, despite doubts,” written by Anemona Hartocollis.  I found the article well written but very disturbing.  I will offer no other comments.  Read the article and let me know what you think.

Conclusions

So, it’s another year, another few more pounds, and no new sure-fire ways to trim down and stay trimmed-down.  As I have tried to emphasize in a number of earlier entries on weight loss therapies, almost every diet out there works in the short run but fails in the long run.  I am convinced that for most people, the best way to lose weight and keep it off is to REALLY, REALLY want to lose weight (?maybe goals and resolutions?) is to aim for weight loss of no more than 1 pound per month (my wife’s mantra), to eat only moderate amounts of healthy foods (a la Michael Pollen) with only small amounts of meats/fatty foods, few if any highly processed foods (particularly potato chips and french fries-a painful task), no sugared sodas and sport drinks, AND to exercise regularly- at least 30 minutes 3 days/week.  Good luck.

Just last week, I wrote about the poor outcomes from studies on a new minimally-invasive approach to gastric stapling, via the oral route.  Now, I want to call your attention to an article published last week in the Archives of Surgery that raises questions about the safety and long-term success of current gastric banding procedures.  The study, conducted in Belgium was headed by Dr. Jacques Himpens,  looked at outcomes in patients who had laparoscopic gastric banding procedures performed between 1994-1997.  The study results were alarming; in about 30% of patients, the bands eroded and 60% required additional surgery.  Also, most patients were still quite overweight; patients had ended up losing well less than half of their excess weight.  The investigators concluded that gastric banding procedures “result in relatively poor long-term outcomes.”  The study was limited in that data were available on only about 60% of the total number of patients but it represents one of the few studies out there with long-term data on gastric banding procedures.  Of course, one could take a positive approach to the data- most patients were quite a bit less heavy than they were before the procedure, and about 60% of the patients expressed satisfaction with the surgery.  Anyway, these data illustrate a principle in medicine that I have often written about- one must weight risks vs. benefits for any treatment, be it growth hormone injections or gastric banding.  It is the unknown risks that pose the greatest dilemma in trying to decide if a proposed therapy is a good idea.

Three entries in three days!  I must slow things down so that readers don’t expect a steady stream of entries.  Anyway, I want to update my entry from yesterday and add a few new items.

First, the on-line article in the New York Times March 16, 2011 regarding the demise of Satiety Inc., the company that had promoted gastric stapling via the oral route, was published in the paper version of the newspaper yesterday (“Hoping to Avoid the Knife,” written by Andrew Pollack).  The article is very well-written and is a good review of the entire field of bariatric surgery ( i.e., weight-loss surgery) and approaches that minimize the surgical aspects.

Second, there is another interesting article in the New York Times today about treating obesity.  The article is entitled “Warmed-Over Atkins? Don’t Tell the French,” written by Elaine Sciolino.  Why this article is in the Thursday Styles section of the paper and not the Business Section (where the Pollack article appeared) I haven’t a clue other than the subject is the very stylish French.  Anyway, the article discusses Pierre Dukan, the so-called “French Dr. Atkins.”  Dr. Dukan is not well known in the U.S., but in France he is a giant celebrity and there is even a term to describe his devotees, “Dukanistes.”  What prompted the article is the news that Dr. Dukan’s diet plan will be published in a North American edition (presumably for the first time, and presumably in English) entitled “The Dukan Diet.”  The article discusses the diet, which seems to me to be just about identical to the original Atkins Diet- high protein/high fat/low carbohydrate.  I have no comments regarding the Dukan Diet except that as I have said in the past, almost every diet ever dreamed up, works just fine, but I am not aware of any diets that have shown consistent benefit over the long haul.  Of course I know you will probably buy the book and try the diet.  Whatever.

Finally, I have a bit more about hCG.  I learned yesterday from a physician colleague of mine that hCG is available not only in drop form but also as an oral spray (e.g, KetoMist or ‘My Fat Cure’ Homeotherapeutic HCG Oral Spray).  This physician has been taking a spray dose of the stuff every day for about a year (his wife bought it for him).  He told me it is great stuff and that he lost 30 pounds over the past year.  I told him I was impressed and asked if he did anything else besides taking the spray to achieve such good results.  He smiled and told me that he cut way back on his calories and increased his exercise.  I bit my tongue and didn’t say a word other than to tell him he looked great.

I almost forgot my apology.  Yesterday I was trying to “clean up” my website and delete spam but keep the interesting reader comments.  Well, I managed to delete all of the comments.  Sorry.

Yesterday I wrote an entry on the use of hCG for weight reduction.  Here I want to add a few things about the post and tell you about 2 interesting articles on obesity.  First, regarding my comments about the hCG craze, I want to make clear that I was not trying to be critical about “alternative” medicine, just quackery.  I will be the first to admit that the scientific method has its limitations; many studies of this and that have either “proven” a benefit or lack of benefit for a particular treatment or procedure, where later studies have truly proven the opposite.  So, all of us (health care professionals and consumers) must maintain both a healthy optimism and skepticism about medical procedures and therapies that seem on the fringe.  Don’t get me wrong, I think use of hCG (either homeopathic drops or injections of the real stuff), is a really bad idea as a method to treat obesity.

Changing the subject a bit, I want to call your attention to two interesting articles.  The first, published today in the New York Times on-line (I suspect it will make it into the hard-copy paper in the next day or so).  The article was entitled “Hoping to Avoid the Knife,” and written by Andrew Pollack.  The article reported that the “scar-less” weight loss surgery technique developed by Satiety, Inc., turned out to be a bust and venture capitalists who put $86 million dollars into the project have pulled out of the project.  The idea was to avoid all the problems with general anesthesia and scars that come with traditional stomach shrinkage procedures used for weight reduction (e.g., gastric-bypass, lap-banding) and cut costs.  Anyway, apparently, the study results were not so hot.  What I found interesting about the article, other than the bad news for Satiety, Inc., was the long discussion about the current state of things with all types of surgical procedures for weight reduction.

The second article was published today the New England Journal of Medicine and is entitled “Obesity Prevalence in the United States- Up, Down, or Sideways.”  The article was written by Susan and Jack Yanovski and although it is an editorial, is a beautiful summary of the various recent data sets that have examined the prevalence of obesity in the U.S.  There are some differences in the data among the various data sets; one can debate whether the prevalence of obesity has stabilized or is still increasing but two things are clear.  First, the prevalence of obesity in the U.S. is astonishingly high and this poses a serious health threat.  Second, even if the overall prevalence is not increasing, the percentage of people with extreme obesity (BMI equal or greater than 40) is climbing steadily.  The authors offer a very interesting discussion about what we should do about the problem.  I highly recommend that you read the article.

As an endocrinologist, I probably should know quite a bit about all the various hormones out there.  But, somehow I fell down on the job.  It is only in the past week or so that I learned about the hCG/weight loss craze.  It’s all over the news and the internet.  The other night I saw 3 hCG ads on TV.  What is this all about?

Human Chorionic Gonadotropin or hCG for short, is a glycoprotein hormone that is produced mainly in the placenta (the fetus and various tumors can also make the hormone).  As the name implies, the hormone stimulates the gonads, akin to the pituitary gonadotropins, luteinizing hormone (LH) and follicule-stimulating hormone (FSH).  It was discovered in 1919 and within a few years it was found to be  useful as a pregnancy test.  The “A-Z test” (named for Asheim and Zondek) was based on the fact that the urine of pregnant women promoted ovarian follicular development, ovulation, and formation of the corpus luteum (the “scar” in the ovary formed after ovulation and the site of progesterone production).  In the 1930s it was established that hCG was a placental hormone.  In the 1940, the hormone was purified.  We now know that the hormone consists of 2 subunits, alpha and beta.  The alpha subunit is virtually identical to several other pituitary hormone alpha subunits including LH and FSH and thyroid-stimulating hormone (TSH).  In addition, the beta subunit of hCG is very similar to that of LH and, as we will discuss, hCG works a lot like LH.

What does hCG do?

Although the function of hCG in pregnancy is not completely understood, most experts believe the hormone is critical to maintain the function of the corpus luteum ( i.e., adequate progesterone production) during early pregnancy.  The hormone level in the blood (and urine) rises rapidly in early pregnancy, reaches a peak at about 10-12 weeks and then gradually declines to a steady but low level throughout the rest of  pregnancy.  Not surprisingly, the hormone level is higher in pregnancies with multiple fetuses.  Levels are very high in cases of maternal isoimmunization (i.e., Rh factor disease) and in women with hydatidiform mole or choriocarcinoma.

Clinically, other than its use as a pregnancy test, hCG has been used mostly as a fertility drug, in women to stimulate ovulation, and in men, to stimulate sperm production.  The hormone is also used by pediatric endocrinologists and urologists in an effort to coax undescended testes into the scrotum.  I do not think it is used much these days for this purpose

The use of hCG for weight reduction

The idea of using hCG as a diet drug seems to have come from the work of a British endocrinologist named Albert Simeons.  Don’t ask me why, but Simeons studied the use of hCG injections for weight reduction in pregnant women and overweight boys in India.   He found that treating these patients with extremely low-calorie diets (500 kcal/d) for several months at a time and low-dose hCG injections resulted in impressive weight loss that was mostly fat tissue, not lean body mass (i,e, muscle).  Apparently, the idea caught on and for quite a number of years, hCG has been widely used (but below my radar) as a weight-loss drug.  As best I can tell, there are no convincing scientific data to show any weight loss benefit from hCG (a very good reference on the subject is Lijesen GK et al: Br J Clin Pharmacol 1995;40:237-43).  Various medical professional organizations have issued warnings about the ineffectiveness of hCG for weight loss.

Homeopathic hCG

Perhaps, the most interesting development has been the rapid rise in the popularity of oral hCG, so-called “homeopathic hCG.”  This product comes in the form of drops and can be purchased from numerous sites on the internet.  The sites typically consist of pages and pages of testimonials and how to purchase the product.  I do not know if it is true, but an article in Wikipedia states that the U.S. Food and Drug Administration has deemed homeopathic hCG  an illegal substance and it is not protected as a homeopathic drug.  I am not aware of any credible scientific studies showing any health benefit from these oral products.   One would not expect any benefit since “real” hCG is only biologically active when taken by injection.  As you might expect, homeopathic hCG drops are very expensive, with typical treatment courses costing many hundreds of dollars.

Injectable  hCG

What about hCG injections?  There is no question that injected hCG is biologically active and has legitimate medical uses in the treatment of infertility.  In men, hCG acts about like LH to stimulate testis testosterone production.  In fact, hCG has been used by drug doping athletes to normalize testis size after they have taken high dose testosterone injections to enhance athletic performance; the testosterone injections inhibit LH secretion, resulting in shrinkage of the testes.  In women, the effects of hCG are complex.  The hormone can promote ovulation,  and as discussed earlier, it can help support the corpus luteum and progesterone production.  The hormone can also lead to increases in estrogen production by first stimulating synthesis of testosterone in the ovary which is then converted into estrogen by enzymes in the ovarian granulosa cells.  Unfortunately, in some patients, hCG injections can result in the ovarian hyperstimulation syndrome in which very large increases in testosterone occur.  The condition can be life-threatening with the development of massive edema and vascular thromboses.   Many other hCG side effects have been reported.  Of course, when used as fertility drug, hCG injections can greatly increase a woman’s chances of having a multiple pregnancy.    Anyway, if hCG doesn’t really help promote weight loss, it is my opinion that the possible therapeutic risks (many) outweigh any possible benefits (none proven).

What is most amazing to me is that apparently many insurers will cover the cost of hCG injections for weight loss if prescribed by a physician .  The hormone is marketed by several pharmaceutical companies (e.g., brand names include Chorex, Novarel, Pregnyl, and Profasi).  Even without insurance coverage, the cost of injectable hCG is quite low, about $2.00/injection (a good summary of the costs and side effects can be found at eHow.com).

Who said our health care system is broken?