Will dietary counseling, food stamp rules help solve obesity epidemic?
More than 30 percent of South Carolina’s population is obese.
What is obesity?
Obese isn’t just an adjective; it’s a technical medical term.
A person is considered obese if his or her Body Mass Index, or BMI, is 30 or higher.
Body Mass Index is a function of height and weight.
For example, a woman who is 5 feet 3 inches tall is considered obese at 170 pounds. A 5-foot-8 man who weighs 197 pounds is also obese.
Your own BMI can be easily calculated by your health care provider or by using a BMI calculator on the National Institutes of Health website, www.nih.gov.
National Institutes of Health
We’re tied with Indiana for eighth fattest state in the country, according to the federal government.
What is bariatric surgery?
Simply put, bariatric surgery has proven to be the most effective way for obese people to lose weight.
Dr. Neil McDevitt, a bariatric surgeon and the director of bariatric services at Summerville Medical Center explained that, technically, it’s an umbrella term used for a number of procedures designed to restrict how much you can eat and how many calories, fat and nutrients your body can absorb from the food you eat.
The oldest and most expensive type of bariatric surgery is the Roux-en-Y gastric bypass, which reduces the size of the stomach and blocks absorption.
“We staple the stomach down to about the size of an egg,” McDevitt said. “Then what we do is reroute it so we’re skipping about a third of the small intestine. It limits how much you can eat and then what you do eat, not all of it can be absorbed.”
Gastric bypass surgery, which ranges from about $25,000 to $40,000, has the longest proven history, McDevitt said.
“The LAP-BAND is probably the least invasive of all the procedures that we do — it turns the stomach into an hourglass,” he said. “It helps you feel fuller, faster and longer.”
The LAP-BAND procedure uses an inflatable ring that can be adjusted over time to restrict the stomach volume.
A third option, called a sleeve gastrectomy, staples the stomach into the shape of a banana with similar results to the LAP-BAND, he said. These procedures range in price from about $13,000 to $17,000.
To be considered for such surgery, a patient must weigh at least 100 pounds over ideal body weight or be at least 75 pounds overweight if he or she has life-threatening co-morbidities. The patient also must be willing to participate in a comprehensive program that includes nutrition counseling, psychological counseling and exercise, McDevitt said.
But renewed focus by leaders to solve this problem may help South Carolina residents lose weight and ultimately save tons of money on government-subsidized health care costs.
To that end, Gov. Nikki Haley has suggested restricting what food stamp recipients can buy at the supermarket with their vouchers. The federal Affordable Care Act will require insurers to cover some preventive services to encourage weight loss. The American Medical Association and South Carolina’s Medicaid agency have officially classified obesity as a disease this year. Medicaid is trying to implement a plan that will start reimbursing registered dietitians to counsel obese Medicaid patients.
South Carolina’s high obesity rates face tough odds. The obesity rate is much higher in rural counties. For example, 58 percent of women in Allendale County are obese — that’s the sixth-highest rate of any county in the U.S. The Centers for Disease Control and Prevention estimates the national average of adults who are obese is about 27 percent.
This does not include people who are simply overweight; that’s a medical term for the range between normal weight and obesity.
But biology works against us in powerful ways.
Humans are programmed to eat and rest, and there’s a good chance most people will never actually lose weight. And even when they do, those pounds often bounce back — plus some.
This isn’t pessimistic; it’s proven.
“I think our physiology is just geared to facilitate eating. We’re just set up to eat,” said Jim Hill, executive director of the University of Colorado’s Anschutz Health and Wellness Center and a leading obesity expert. “And there’s not very much we can to do stop eating. In order to achieve energy balance because we like to eat, we can become active or we can become obese.”
The reality is that the medical community and the insurance community are struggling to figure out what works, said Tony Keck, who runs the state Medicaid agency.
“We’re trying to design something that works comprehensively,” Keck said.
That includes a proposal, which must be approved by the federal government, to allow registered dietitians to counsel the state’s estimated 146,635 low-income obese Medicaid patients about healthy eating. Each Medicaid patient would be eligible for a maximum six 30-minute sessions with a dietitian each year.
“It seems like the climate is changing,” said Nina Crowley, a Medical University of South Carolina dietitian who helped the state’s Medicaid agency develop this plan. “Insurance companies are realizing this is cost-effective. (Dietitians) can do it cheaper and more effectively than doctors.”
That’s because for hospitals and health care providers, promoting wellness — actually preventing disease — isn’t always profitable.
“Part of the problem is just the way our economic system is set up,” said Debbie Petitpain, also a registered dietitian at MUSC. “Why don’t we have a medication to prevent obesity? Where’s the money in that?”
The cost of obesity
MUSC bills insurance companies about $25,000 for bariatric surgery, and only an average $30 for a 15-minute initial consultation with a dietitian, she said.
The cost of obesity
Prevention may not make hospitals and providers much money, but insurers, including the Medicare and Medicaid programs, stand to save millions.
A CDC report says obesity-related health care costs approached $147 billion in 2008. And the country has gained weight since then.
Data released this month by the Institute for Health Metrics and Evaluation show national obesity rates for men and women have increased by more than 6 percent since 2001.
Blue Cross Blue Shield of South Carolina, the state’s largest health insurer, does not currently cover nutrition counseling, except for some patients with specific health issues like diabetes. It also does not cover bariatric surgery, the most effective way for obese adults to lose weight.
“Nationwide, very few health plans cover nutritional counseling,” said Patti Embry-Tautenhan, a spokeswoman for Blue Cross Blue Shield of South Carolina. “It is worth noting that adding benefits also adds additional costs to the consumer, and our customers are understandably price sensitive.”
The S.C. Medicaid agency expects that dietitians will be allowed to advise Medicaid patients starting this fall, pending federal approval. Similar plans in other states already have been approved by the Centers for Medicare & Medicaid.
Another state government proposal to cut out junk food from the approved list of items that Supplemental Nutrition Assistance Plan (SNAP) recipients can buy with their vouchers also must be approved by the federal government. If approved, it would be the first of its kind in the country, but other states have tried to restrict approved SNAP foods before and failed to win federal approval.
Still, Keck is optimistic that these efforts will pay off.
“I think we’re at a point where we have enough tools to really put toward this problem,” he said.
But there’s no guarantee that three hours spent with a dietitian will help someone lose weight, especially those with so much to lose.
“I’m a dietitian. I would love to say diet and lifestyle works. And yes, diet and lifestyle work for some people … but research shows that diet and lifestyle gets off a small percentage of weight, and it’s more likely to come back on over time,” Petitpain said.
“There is not one right answer and there is not one right treatment approach,” she said. “Clinicians are constantly at a tug of war with epidemiologists and public health policy makers in the fact that they want a one-size-fits-all rule, but for a lot of people that’s not how it works.”
Hill, of the University of Colorado, said obesity experts have many tactics, including nutrition counseling, but no battle plan — at least not one that’s working.
“We spend a lot of energy getting excited about one thing and then we do that one thing and it doesn’t work,” he said. “Look at how much attention we give to (obesity), and yet nothing is happening. It makes me think we aren’t focusing our energy in exactly the right way.”
Reach Lauren Sausser at 937-5598.