ReportWire

Tag: assistant professor

  • BMI Won’t Die

    BMI Won’t Die

    [ad_1]

    If anything defines America’s current obesity-drug boom, it’s this: Many more people want these injections than can actually get them. The roadblocks include exorbitant costs that can stretch beyond $1,000 a month, limited insurance coverage, and constant supply shortages. But before all of those issues come into play, anyone attempting to get a prescription will inevitably confront the same obstacle: their body mass index, or BMI.

    So much depends on the simple calculation of dividing one’s weight by the square of their height. According to the FDA, people qualify for prescriptions of Wegovy and Zepbound—the obesity-drug versions of the diabetes medications Ozempic and Mounjaro—only if their BMI is 3o or higher, or 27 or higher with a weight-related health issue such as hypertension. Many who do get on the medication use BMI to track their progress. That BMI is the single biggest factor determining who gets prescribed these drugs, and who doesn’t, is the result of how deeply entrenched this metric has become in how both doctors and regular people approach health: Low BMI is good and high BMI is bad, or so most of us have come to think.

    This roughly 200-year-old metric has never been more relevant—or maligned—than it is in the obesity-drug era. BMI has become like the decrepit car you keep driving because it still sort of works and is too much of a hassle to replace. Its numerous shortcomings have been called out for many years now: For starters, it accounts for only height and weight, not other, more pertinent measures such as body-fat percentage. In June, the American Medical Association formally recognized that BMI should not be used alone as a health measure. Last year, some doctors called for BMI to be retired altogether, echoing previous assertions.

    The thing is, BMI can be an insightful health metric, but only when used judiciously with other factors. The problem is that it often hasn’t been. Just as obesity drugs are taking off, however, professional views are changing. People are so accustomed to seeing BMI as the “be-all, end-all” of health indicators, Kate Bauer, a nutritional-sciences professor at the University of Michigan, told me. “But that’s increasingly not the way it’s being used in clinical practice.” A shift in the medical field is a good start, but the bigger challenge will be getting everyone else to catch up.

    BMI got its start in the 1830s, when a Belgian astronomer named Adolphe Quetelet attempted to determine the properties of the “average” man. Using data on primarily white people, he observed that weight tended to vary as the square of height—a calculation that came to be known as Quetelet’s index.

    Over the next 150 years, what began as a descriptive tool transformed into a prescriptive one. Quetelet’s index (and other metrics like it) informed height-weight tables used by life-insurance companies to estimate risk. These sorts of tables formed “recommendations for the general population going from ‘average’ to ‘ideal’ weights,” the epidemiologist Katherine Flegal wrote in her history of BMI; eventually, nonideal weights were classified as “overweight” and “obese.” In 1972, the American physiologist Ancel Keys proposed using Quetelet’s index—which he renamed BMI—to roughly measure obesity. We’ve been stuck with BMI ever since. The metric became embedded not only in research and doctor’s visits but also in the very definitions of obesity. According to the World Health Organization, a BMI starting at 25 and less than 30 is considered overweight; anything above that range is obese.

    But using BMI to categorize a person’s health was controversial from the start. Even Keys called it “scientifically indefensible” to use BMI to judge someone as overweight. BMI doesn’t account for where fat is distributed on the body; fat that builds up around organs and tissues, called visceral fat, is linked to serious medical issues, while fat under the skin—the kind you can pinch—is usually less of a problem. Muscularity is also overlooked: LeBron James, for example, would be considered overweight. Both fat distribution and muscularity can vary widely across sex, age, and ethnicity. People with high BMIs can be perfectly healthy, and “there are people with normal BMIs that are actually sick because they have too much body fat,” Angela Fitch, an assistant professor at Harvard Medical School and the president of the Obesity Medicine Association, told me.

    For all its flaws, BMI is actually useful at the population level, Fitch said, and doctors can measure it quickly and cheaply. But BMI becomes troubling when it is all that doctors see. In some cases, the moment when a patient’s BMI is calculated by their doctor may shape the rest of the appointment and relationship going forward. “The default is to hyper-focus on the weight number, and I just don’t think that that’s helpful,” Tracy Richmond, a pediatrics professor at Harvard Medical School, told me. Anti-obesity bias is well documented among physicians—even some obesity specialists—and can lead them to dismiss the legitimate medical needs of people with a high BMI. In one tragic example, a patient died from cancer that went undiagnosed because her doctors attributed her health issues to her high BMI.

    But after many decades, the medical community has begun to use BMI in a different way. “More and more clinicians are realizing that there are people who can be quite healthy with a high BMI,” Kate Bauer said. The shift has been gradual, though it was given a boost by the AMA policy update earlier this year: “Hopefully that will help clinicians make a change to supplement BMI with other measures,” Aayush Visaria, an internal-medicine resident at Rutgers Robert Wood Johnson Medical School who researches BMI’s shortcomings, told me.

    Physicians I spoke with acknowledged BMI’s flaws but didn’t seem too concerned about its continued use in medicine—even as obesity drugs make this metric even more consequential. BMI isn’t a problem, they said, as long as physicians consider other factors when diagnosing obesity or prescribing drugs to treat it. If you go to a doctor with the intention of getting on an obesity drug, you should be subject to a comprehensive evaluation including metrics such as blood sugar, cholesterol levels, and body composition that go “way beyond BMI,” Katherine Saunders, a clinical-medicine professor at Weill Cornell Medicine, said. Because Wegovy and other drugs come with side effects, she told me, doctors must be absolutely sure that a patient actually needs them, she added.

    But BMI isn’t like most other health metrics. Because of its simplicity, it has seeped out of doctor’s offices and into the mainstream, where this more nuanced view still isn’t common. Whether we realize it or not, BMI is central to our basic idea of health, affecting nearly every aspect of daily life. Insurance companies are notorious for charging higher rates to people with high BMI and lowering premiums for people who commit to long-term weight loss. Fertility treatments and orthopedic and gender-affirming surgery can be withheld from patients until they hit BMI targets. Workplace wellness programs based on BMI are designed to help employees manage their weight. BMI has even been used to prevent prospective parents from adopting a child.

    The rise of obesity drugs may make these kinds of usages of BMI even harder to shake. Determining drug eligibility by high BMI supports the notion that a number is synonymous with illness. Certainly many people using obesity drugs take a holistic view of their health, as doctors are learning to do. But focusing on BMI is still common. Some members of the r/Ozempic Subreddit, for example, share their BMI to show their progress on the drug. Again, high BMI can be used to predict who has obesity, but it isn’t itself an obesity diagnosis. The problem with BMI’s continued dominance is that it makes it even harder to move away from simply associating a number on a scale with overall health, with all the downstream consequences that come along with a weight-obsessed culture. As obesity drugs are becoming mainstream, “there needs to be public education explaining that BMI by itself may not be a good indicator of health,” Visaria said.

    In another 200 years, surely BMI will finally be supplanted by something else. If not much sooner: A large effort to establish hard biological criteria for obesity is under way; the goal is to eliminate BMI-based definitions once and for all. Caroline Apovian, a professor at Harvard Medical School, gives it “at least 10 years” before a comparably cheap or convenient replacement arises—though any changes would take longer to filter into public consciousness.” Until that happens, we’re stuck with BMI, and the mess it has wrought.

    [ad_2]

    Yasmin Tayag

    Source link

  • The Election Reform That Could Help Republicans in a Swing State

    The Election Reform That Could Help Republicans in a Swing State

    [ad_1]

    When Governor Josh Shapiro of Pennsylvania announced in September that the nation’s largest swing state would implement automatic voter registration, Donald Trump threw a conniption. “Pennsylvania is at it again!” the former president posted on Truth Social, his social-media platform. The switch, Trump said, would be “a disaster for the Election of Republicans, including your favorite President, ME!”

    Trump’s panic is consistent with his (baseless) view that any reforms designed to increase voter turnout, such as expanding mail balloting and early voting, are part of a Democratic conspiracy to rig elections in their favor. But he may be wrong to fear automatic voter registration: Although Shapiro is a Democrat, if either party stands to gain from his move, it’s likely to be the GOP. In Pennsylvania, the reform “really has a potential to lean more Republican,” Seo-young Silvia Kim, an elections expert who has studied the system, told me. It’s “not great news for Democrats.”

    First implemented in Oregon in 2016, automatic voter registration is now used in 23 states, including three—Alaska, Georgia, and West Virginia—that are governed by Republicans. Rather than requiring citizens to proactively register to vote, some states that use the system automatically enroll people who meet eligibility requirements and then give them the option to decline or opt out. The shift is subtler in Pennsylvania; the state has simply started prompting people to register to vote when they obtain a new or renewed driver’s license or state ID.

    David A. Graham: Actually good news about voting, for a change

    The seemingly minor change, which voting-rights advocates still place under the umbrella of “automatic” registration, is based on behavioral research showing that people are less likely to opt out of a choice than to opt in. By including voter registration as part of a commonly used process such as obtaining a driver’s license—and by presenting it as the default option rather than a form that citizens have to request—states have found that they can increase both registration and turnout in elections. “Even though the process isn’t that big of a shift, the effects are great,” Greta Bedekovics, the associate director of democracy policy at the left-leaning Center for American Progress, told me.

    Democrats have led the move toward automatic voter registration, and their 2021 comprehensive voting-rights legislation known as the For the People Act included a requirement that state-elections chiefs implement the policy. (The bill died in the Senate.) But automatic registration does not inherently favor one party or the other, and it has appealed to Republicans in some states because it helps officials clean up voter rolls and safeguard elections. “I don’t know who it will help, and that’s kind of the point,” Sean Morales-Doyle, the director of the voting-rights program at NYU’s Brennan Center for Justice, told me.

    A 2017 study by the Center for American Progress found that the voters who enrolled through Oregon’s automatic-registration system were more likely to be younger, more rural, lower income, and more ethnically diverse than the electorate as a whole—a demographic mix that suggests that Republicans might have benefited as much as Democrats.

    Other research shows a more partisan advantage. While an assistant professor at American University in 2018, Kim, the elections expert, studied the effects of automatic registration in Orange County, California, the site of several hard-fought congressional races that year. She found that among residents who needed to update their registration because they had moved within the county, automatic registration resulted in no meaningful shift for Democrats. But it substantially boosted turnout among Republicans and independents—by 8.1 points and 7.4 points, respectively. “I was actually very surprised,” Kim said, adding that she’d expected that if any party gained, it would be Democrats. She suspects that Democrats may have been unaffected by the change because in 2018, they were already motivated to vote by Trump’s recent election.

    The impact of automatic registration on any one election is likely to be marginal, but even small shifts could be significant in a state such as Pennsylvania, where less than one percentage point separated Trump from Hillary Clinton in 2016 and just more than one point separated Joe Biden from Trump four years later. Several factors suggest that the new system could benefit the GOP in Pennsylvania. Although Democrats have more registered voters in the state, Republicans have been closing the gap during the Trump era as more white working-class and rural voters who stopped voting for Democrats years ago have chosen to join the GOP. Democrats have countered that drift by capturing wealthier suburban voters, a group that helped Shapiro and first-term Democratic Senator John Fetterman win their races during last year’s midterm elections. Because this demographic already goes to the polls pretty reliably, though, automatic registration is more likely to boost turnout among the right-leaning rural working class.

    An early-2020 study also suggested that the GOP stood to gain from higher voter turnout in Pennsylvania. The Knight Foundation surveyed 12,000 “chronic non-voters” nationwide before Democrats had settled on Biden as their nominee. Across the country, nonvoters said that if they cast a ballot, they would support the Democratic candidate over Trump by a slim margin, 33 percent to 30 percent. But in Pennsylvania, nonvoters went strongly in the other direction: By a 36–28 percent margin, they said they’d prefer Trump over the Democrat. The eight-point gap was the second largest (after Arizona) in favor of Trump in any of the 10 swing states that the organization polled.

    Jerusalem Demsas: Americans vote too much

    “Democrats sometimes have the mistaken opinion that anybody that doesn’t show up is going to vote Democrat,” Mike Mikus, a longtime Democratic strategist in Pennsylvania, told me. “It’s been one of the myths in Democratic circles for years. Quite frankly, given the changing of the respective party bases, it makes sense that [automatic registration] may somewhat benefit Republicans.” Other recent polls have suggested that the political realignment of the Trump era has made the GOP more reliant on infrequent voters.

    The place where Democrats could most use stronger turnout—particularly among the party’s base of Black voters—is Philadelphia, which provided about one-sixth of Biden’s statewide vote in 2020. The city had higher turnout than Pennsylvania as a whole in both 2008 and 2012, when Barack Obama led the Democratic ticket, but it has lagged further and further behind in each election since. Last year, turnout in Philadelphia was just 43 percent, compared with 54 percent statewide.

    Yet automatic voter registration might have less impact in Philadelphia than in other parts of the state. Studies have found that the switch drives higher turnout outside urban areas, where Democratic voters are most concentrated. That’s partly because automatic voter registration is operated through the state Department of Motor Vehicles—an agency with which people who rely on public transit are less likely to interact. For that reason, when New York implemented automatic registration in 2020, voting-rights advocates lobbied aggressively for the state to enroll voters through other agencies in addition to the DMV; as of 2018, a majority of the more than 3 million households in New York City did not own a car.

    Pennsylvania has no plans to implement automatic voter registration beyond the state DMV. Democrats have been adamant that in enacting the new system, Shapiro was not trying to benefit his party but merely trying to reach the 1.6 million Keystone State residents who are eligible but not registered to vote. Although Republicans argued that the change should have gone through the state legislature, they have not formally challenged automatic registration in court. Few of them seemed to agree with Trump that the reform would doom the GOP. “Its impact will be somewhere between inconsequential and a nothingburger,” Christopher Nicholas, a Republican consultant in Pennsylvania, told me.

    Democrats say it’s too early to assess the electoral impact of automatic voter registration, but they acknowledged that Republicans might gain more voters as a result. More than 13,500 Pennsylvanians registered to vote through the new system during its first six weeks of implementation, according to numbers provided by the Shapiro administration. Of that total, Republicans added about 100 more voters than Democrats. “Our former president is almost always wrong,” Joanna McClinton, who leads a narrow Democratic majority as the speaker of the Pennsylvania state House, told me. The fact that Trump is so opposed to the reform, she said, “reveals something we’ve always known, which is Republicans want to keep the electorate small, selective, and they don’t want to expand access to voting even if they could be the beneficiaries of it.”

    Whether Trump regains the presidency next year could hinge on the tightest of margins in Pennsylvania. I asked McClinton if she worried that by implementing automatic voter registration, Shapiro had unintentionally bestowed an electoral gift on Republicans ahead of an enormously significant election. McClinton didn’t hesitate. “Not at all,” she replied quickly. “I look forward to seeing the full data, but I definitely am not looking at this from a political perspective but from a big-D democracy perspective.”

    [ad_2]

    Russell Berman

    Source link

  • What the Polls May Be Getting Wrong About Trump

    What the Polls May Be Getting Wrong About Trump

    [ad_1]

    In the months since Donald Trump’s indictments started piling up, pollsters have noticed something remarkable: The dozens of criminal charges brought against the former president have seemed to boost his standing in the Republican presidential primary. Trump has widened his already commanding lead over his rivals, and in poll after poll, GOP voters have said that the charges make them more—not less—likely to vote for him again.

    The dynamic has turned an infamous example of Trumpian bravado—his 2016 claim that “I could stand in the middle of 5th Avenue and shoot somebody and I wouldn’t lose voters”—into something approaching a prophecy. To his critics, the emerging conventional wisdom that the indictments have benefited Trump politically is a dispiriting and even dangerous notion, one that could embolden politicians of any ideological stripe to disregard the law.

    Those fears, however, may be premature.

    David A. Graham: The Georgia indictment offers the whole picture

    A new, broader survey of Republican voters suggests that the indictments have, in fact, dented Trump’s advantage in the primary. The study was designed by a group of university researchers who argue that pollsters have been asking the wrong questions to assess how the indictments have affected Republican voters.

    Most traditional polls have asked respondents directly whether the indictments have changed their attitude about Trump or their likelihood to vote for him. According to Matt Graham, one of the authors of the new survey and an assistant professor at Temple University, this type of query leads to biased answers. And it devolves into a proxy question for whether voters—and Republicans in particular—like the former president in the first place. “Respondents don’t always answer questions the way we want them to,” Graham told me. Republicans “want to say, ‘Well, I still support him regardless of the indictment.’ And if you don’t give them a chance to say that, they’re going to use the question to say that.”

    The researchers spotted a similar polling flaw in the high-profile 2017 special election for an open Senate seat in Alabama, where Republicans told pollsters that the many accusations of sexual assault against Roy Moore only made them more likely to support him. Moore went on to lose the election to Democrat Doug Jones after a sizable number of Republicans deserted him in a deeply red state.

    Graham and his colleagues believed that they could elicit more accurate answers about Trump by asking respondents to assess their view of him—and their likelihood of voting for him—as if they did not know he had been indicted. To test their theory, they commissioned a SurveyMonkey poll of more than 5,000 Americans in which half were asked questions in this counterfactual format: “Suppose you did not know about the indictment. How would you have answered the following question: How likely are you to vote for Donald Trump?” They asked the other half questions that pollsters more commonly use.

    The experiment produced significantly different results. Like other surveys, the poll based on the traditional format found that the indictments increased Trump’s support among Republican primary voters. But the poll based on the counterfactual framing found that the indictments slightly hurt his standing in the party, reducing by 1.6 percent the likelihood that Republicans would vote for him.

    The real-world implications of the researchers’ findings are, well, limited—at least for now. Trump’s polling lead in the early voting states of Iowa and New Hampshire averages more than 25 points; the gap widens to nearly 40 points in recent national surveys. A drop of 1.6 percent suggests that charging Trump with multiple felonies is akin to tossing a pebble at a fast-moving train. “I don’t know that I make much of it at all,” Sarah Longwell, a Republican strategist who regularly conducts focus groups of voters, told me.

    In Longwell’s experience, the response from Trump supporters to the indictments has been consistent for months: “They say they do not care about them.” Views about the former president have been locked in place for years, Longwell said, and most Trump supporters give either a neutral response to the indictments or say that the charges make them even more likely to vote for him. Almost no one, she told me, said the indictments make them less supportive.

    Watch: Making sense of Donald Trump’s 91 felony charges

    If anything, they help Trump reclaim the status of an outsider fighting establishment forces, which was central to his appeal in 2016, says Chris Jackson, the head of public polling at Ipsos, a nonpartisan research firm that frequently conducts surveys for news organizations. In Jackson’s surveys, Republican voters have told pollsters that the indictments make them more likely to support Trump. Still, he told me, he doesn’t think the charges themselves are helping Trump’s candidacy: “I think the media attention that the indictments have created have helped him.”

    In polls conducted by Ipsos and other firms, Trump has widened his lead among Republican primary voters since he was indicted by a grand jury in New York this spring. But that shift, Jackson said, is less about Trump than about his opponents, and particularly Governor Ron DeSantis of Florida, who has lost support during that time. “He hasn’t actually gained in his share of the Republican electorate,” Jackson said. “I don’t actually think Trump’s strengthened so much as his challengers have weakened.”

    Jackson’s interpretation of the polling data is similar to what Graham and his colleagues found in their counterfactual experiment: The indictments may not have hurt Trump much among Republican voters, but they haven’t really boosted him either. “The way a question is worded always has an impact in survey research,” Jackson said. “So, yeah, I think it matters, but it’s not necessarily uncovering some deeper truth.”

    Graham, too, isn’t arguing that his team’s findings should fundamentally alter perceptions about Trump’s chances of becoming the Republican nominee. But he believes that the emerging and, it seems, false narrative that charging a political candidate with dozens of serious crimes will redound to his benefit is an important one to dispel. “I don’t think that survey researchers should be sending the public profoundly pessimistic messages about how their fellow citizens think and reason when those aren’t actually true,” Graham told me. “There’s plenty to be pessimistic about in our politics, but we don’t need to pile on by acting like people think that indictments are good.”

    [ad_2]

    Russell Berman

    Source link

  • Ozempic in Teens Is a Confusing Mess

    Ozempic in Teens Is a Confusing Mess

    [ad_1]

    Somehow, America’s desire for Ozempic is only growing. The drug’s active ingredient, semaglutide, is sold as an obesity medication under the brand name Wegovy—and it has become so popular that its manufacturer, Novo Nordisk, recently limited shipments to the U.S. and paused advertising to prevent shortages. Its promise has enticed would-be patients and set off a pharmaceutical arms race to create more potent drugs.

    Part of the interest stems from Ozempic’s potential in teens: In December, the FDA approved Wegovy as a treatment for teenagers with obesity, which affects 22 percent of 12-to-19-year-olds in the United States. The drug’s ability to spur weight loss in adolescents has been described as “mind-blowing.” In January, in its new childhood-obesity-treatment guidelines, the American Academy of Pediatrics (AAP) recommended that doctors consider adding weight-loss drugs such as semaglutide as a treatment for some patients.

    But although many doctors and obesity experts have embraced semaglutide as a treatment for adults, some are concerned that taking it at such a young age—and at such a precarious stage of life—could pose serious risks, especially because the long-term physical and mental-health effects of the medication are still unknown. Others, however, believe that not using this medication in adolescents is riskier, because obesity makes teens vulnerable to serious health conditions and premature death. In part because of the apprehension among doctors, prescriptions for semaglutide in teens are not taking off like they are for adults. At this point, whether these drugs will ever catch on as a treatment for teens remains deeply uncertain.

    Semaglutide isn’t just effective for teens; it may be even more effective than it is in adults. In a large Novo Nordisk–funded study published in The New England Journal of Medicine, “the degree of weight reduction in adolescents was better than what was observed in the adult trials,” Aaron S. Kelly, a co-director of the Center for Pediatric Obesity Medicine at the University of Minnesota Medical School, told me. In another Novo Nordisk–funded study published last week, a team led by Kelly showed that the drug, combined with counseling and exercise, nearly halved the number of teens with obesity after they received 68 weeks of treatment. Both for adolescents and adults, the weekly injection doesn’t “magically melt away body fat,” Kelly said; instead, it works by triggering a sense of fullness and quieting hunger pangs.

    Teenagers’ experience with obesity is different—in some ways more intense—than that of older people. Puberty is a time of lots of growth and development, so the body fights off attempts at weight loss “with every mechanism that it has,” Tamara Hannon, a pediatric endocrinologist at the Indiana University School of Medicine, told me. Teenagers may also have less control than adults over what they eat or how much activity they get, because these are largely circumscribed by their family and school, as well as by social pressure to conform to how their peers eat. “Making good choices means doing something different than the majority of the other kids,” Hannon said. “At every corner, there’s something that is in direct opposition to losing weight.”

    Because obesity is a chronic disease, developing it early can be devastating. In many cases, it can result in illnesses such as type 2 diabetes and fatty liver at a young age. Children with obesity are five times more likely than their peers to have it in adulthood; as teens with obesity become adults with obesity, they can “develop very, very aggressive disease,” Fatima Stanford, an obesity-medicine physician at Massachusetts General Hospital and Harvard Medical School, told me. Weight-loss drugs give doctors the ability to intervene before the effects of obesity snowball, she said, which is why AAP’s new childhood-obesity guidelines advocate for using them as part of early, aggressive treatment—along with many hours of in-person health and lifestyle therapy. Used early enough, semaglutide or other medications could possibly reroute the trajectory of a teenager’s entire life.

    But semaglutide could also possibly throw a teen’s trajectory off course. Because treatment is considered a lifelong endeavor—stopping usually leads to rapid weight regain—adolescents who start the medication will be taking it for many decades. “We have no way of knowing whether these drugs, used so early in life for so long, could have unanticipated adverse effects,” David Ludwig, an endocrinologist at Boston Children’s Hospital, told me. Although adults face many of the same unknowns, the risks for teens could be more severe, because their body and brain are in constant flux. Of particular concern are the drug’s potential impacts on physiological changes specific to adolescence. “We need to keep an eye on pubertal development and menstrual history for girls,” Hannon said. In addition, the drugs can lead to unsavory side effects such as gastrointestinal issues and may have other impacts, including significant muscle loss and rewiring of the brain’s reward circuitry. Scientists are just beginning to understand these effects; at this point, only two major studies have been conducted on semaglutide in teens, and neither has involved a long follow-up period.

    The repercussions of semaglutide treatment on mental health, an important aspect of obesity care, are even less understood. Teens are “more likely than an adult to have intermittent access to medication,” Kathleen Miller, an adolescent-medicine specialist at Children’s Minnesota hospital, told me—and skipping several doses in a row could pose physical and well as psychological risks. Another concern is that the overall effect of taking semaglutide—a decreased appetite, which leads to eating less—is essentially the same as that of dieting. When teens go on very restrictive diets, whether or not they involve weight-loss medications, “we know that may be harmful to their mental health and promote disordered eating,” Hannon said. Because their brain is so plastic during puberty, “there’s a risk of ingraining those patterns in adolescence,” Miller said.

    With so many unknowns, would teens with obesity be better off avoiding semaglutide? At least for now, many pediatricians are reluctant to prescribe it. “The idea of using anti-obesity pharmacotherapy was challenging even in adults a couple of years ago,” says Angela Fitch, an assistant professor at Harvard Medical School and the president of the Obesity Medicine Association; acceptance of its role in pediatric care is even further behind. But denying teens the drug, she told me, is the biggest risk: Teens develop an unhealthy mentality about their body when they don’t get help losing weight. Explaining to a teen that obesity is not their fault, and correcting the underlying biological issue with medication or other treatment, helps them to develop “a better body image about themselves,” she said.

    None of the experts I spoke with flat-out said that semaglutide should never be used in adolescent treatment. Even those who were wary of the drug acknowledged that it might be medically appropriate in teens who really struggle with their weight and have little success losing it through any other means. That argument may only strengthen as more convenient drugs—or those with fewer side effects—are approved for teen use. This week, both Novo Nordisk and Pfizer announced that pill versions of these medications were successful in early trials.

    Even without all of the answers on how this drug might affect teens in the long term, Fitch predicted that “the uptake of semaglutide and other anti-obesity medications in pediatric clinical care will be slow and gradual.” Eventually, they may come to be seen as just one of several weight-loss tools to help set up kids for healthier lives. Treating adolescent obesity shouldn’t be an “either-or” choice, Ludwig said: “It’s everything-and.” He has proposed that combining semaglutide with a low-carbohydrate diet, for example, could have synergistic effects on adolescent weight loss.

    For the foreseeable future, semaglutide isn’t poised to take off for teens in the way that it has for adults. In spite of all the hype surrounding Ozempic, experts and their patients are left with a difficult choice based on different assessments of risk: what might happen if teens are treated with drugs, and what might happen if they’re not. Either way, teenagers have the most to benefit—and the most to lose.

    [ad_2]

    Yasmin Tayag

    Source link

  • Doctors Are Failing Patients With Disabilities

    Doctors Are Failing Patients With Disabilities

    [ad_1]

    This piece was originally published by Undark Magazine.

    Ben Salentine, the associate director of health-sciences managed care at the University of Illinois Hospital and Health Sciences System, hasn’t been weighed in more than a decade. His doctors “just kind of guess” his weight, he says, because they don’t have a wheelchair-accessible scale.

    He’s far from alone. Many people with disabilities describe challenges in finding physicians prepared to care for them. “You would assume that medical spaces would be the most accessible places there are, and they’re not,” says Angel Miles, a rehabilitation-program specialist at the Administration for Community Living, part of the Department of Health and Human Services.

    Not only do many clinics lack the necessary equipment—such as scales that can accommodate people who use wheelchairs—but at least some physicians actively avoid patients with disabilities, using excuses like “I’m not taking new patients” or “You need a specialist,” according to a paper in the October 2022 issue of Health Affairs.

    The work, which analyzed focus-group discussions with 22 physicians, adds context to a larger study published in February 2021 (also in Health Affairs) that showed that only 56 percent of doctors “strongly” welcome patients with disabilities into their practice. Less than half were “very confident” that they could provide the same quality of care to people with disabilities as they could to other patients. The studies add to a larger body of research suggesting that patients with conditions that doctors may deem difficult to treat often struggle to find quality care. The Americans With Disabilities Act of 1990 (ADA) theoretically protects the one in four adults in the U.S. with a disability from discrimination in public and private medical practices—but enforcing it is a challenge.

    Laura VanPuymbrouck, an assistant professor in the Department of Occupational Therapy at Rush University, calls the 2021 survey “groundbreaking—it was the crack that broke the dam a little bit.” Now researchers are hoping that medical schools, payers, and the Joint Commission (a group that accredits hospitals) will push health-care providers for more equitable care.

    Due in part to scant data, information about health care for people with disabilities is limited, according to Tara Lagu, a co-author of both the 2021 and 2022 papers and the director of the Institute for Public Health and Medicine’s Center for Health Services & Outcomes Research at Northwestern University Feinberg School of Medicine. The few studies that have been done suggest that people with disabilities get preventive care less frequently and have worse outcomes than their nondisabled counterparts.

    About a decade ago, Lagu was discharging a patient who was partially paralyzed and used a wheelchair. The patient’s discharge notes repeatedly recommended an appointment with a specialist, but it hadn’t happened. Lagu asked why. Eventually, the patient’s adult daughter told Lagu that she hadn’t been able to find a specialist who would see a patient in a wheelchair. Incredulous, Lagu started making calls. “I could not find that kind of doctor within 100 miles of her house who would see her,” she says, “unless she came in an ambulance and was transferred to an exam table by EMS—which would have cost her family more than $1,000 out of pocket.”

    In recent years, studies have shown that even when patients with disabilities can see physicians, their doctors’ biases toward conditions such as obesity, intellectual disabilities, and substance-use disorders can have profound impacts on the care they receive. Physicians may assume that an individual’s symptoms are caused by obesity and tell them to lose weight before considering tests.

    For one patient, this meant a seriously delayed diagnosis of lung cancer. Patients with mobility or intellectual challenges are often assumed to be celibate, so their providers skip any discussion of sexual health. Those in wheelchairs may not get weighed even if they’re pregnant—a time when tracking one’s weight is especially important, because gaining too little or too much is associated with the baby being at risk for developmental delays or the mother being at risk for complications during delivery.

    These issues are well known to Lisa Iezzoni, a health-policy researcher at Massachusetts General Hospital and a professor of medicine at Harvard Medical School. Over the past 25 years, Iezzoni has interviewed about 300 people with disabilities for her research into their health-care experiences and outcomes, and she realized that “every single person with a disability tells me their doctors don’t respect them, has erroneous assumptions about them, or is clueless about how to provide care.” In 2016, she decided it was time to talk to doctors. Once the National Institutes of Health funded the work, she and Lagu recruited the 714 physicians that took the survey for the study published in 2021 in Health Affairs.

    Not only did many doctors report feeling incapable of properly caring for people with disabilities, but a large majority held the false belief that those patients have a worse quality of life, which could prompt them to offer fewer treatment options.

    During the 2021 study, Iezzoni’s team recorded three focus-group discussions with 22 anonymous physicians. Although the open-ended discussions weren’t included in the initial publication, Lagu says she was “completely shocked” by some of the comments. Some doctors in the focus groups welcomed the idea of additional education to help them better care for patients with disabilities, but others said that they were overburdened and that the 15 minutes typically allotted for office visits aren’t enough to provide these patients with proper care. Still others “started to describe that they felt these patients were a burden and that they would discharge patients with disability from their practice,” Lagu says. “We had to write it up.”

    Read: How wheelchair accessibility ramped up

    The American Medical Association, the largest professional organization representing doctors, declined an interview request and would not comment on the most recent Health Affairs study. When asked about the organization’s policies on caring for patients with disabilities, a representative pointed to the AMA’s strategic plan, which includes a commitment to equity.

    Patients with disabilities are supposed to be protected by law. Nearly 50 years ago, Congress passed Section 504 of the Rehabilitation Act of 1973, which prohibited any programs that receive federal funding, such as Medicare and Medicaid, from excluding or discriminating against individuals with disabilities. In 1990, the ADA mandated that public and private institutions also provide these protections.

    The ADA offers some guidelines for accessible buildings, including requiring ramps, but it does not specify details about medical equipment, such as adjustable exam tables and wheelchair-accessible scales. Although these items are necessary to provide adequate care for many people with disabilities, many facilities lack them: In a recent California survey, for instance, only 19.1 percent of doctor’s offices had adjustable exam tables, and only 10.9 percent had wheelchair-accessible scales.

    Miles says she’s noticed an improvement in care since the ADA went into effect, but she still frequently experiences challenges in health care as a Black woman who uses a wheelchair. “We need to keep in mind the ADA is not a building code. It’s a civil-rights law,” says Heidi Johnson-Wright, an ADA coordinator for Miami-Dade County in Florida, who was not speaking on behalf of the county. “If I don’t have access to a wellness check at a doctor’s office or treatment at a hospital, then you’re basically denying me my civil rights.”

    The ADA isn’t easy to enforce. There are no “ADA police,” Johnson-Wright says, to check if doctor’s offices and hospitals are accessible. In many cases, a private citizen or the Department of Justice has to sue a business or an institution believed to be in violation of the ADA. Lawyers have filed more than 10,000 ADA Title III lawsuits each year since 2018. Some people, sympathizing with businesses and doctors, accuse the plaintiffs of profiteering.

    And it’s not just about accessible equipment. In 2018, the Justice Department sued a skilled nursing facility for violating the ADA, after the facility refused to treat a patient with a substance-use disorder who needed medication to help maintain sobriety. Since then, the department settled with eight other skilled nursing facilities for similar discrimination. “It is a violation of the ADA” to deny someone care based on the medications they need, Sarah Wakeman, an addiction-medicine specialist at Massachusetts General Hospital, wrote in an email, “and yet continues to happen.”

    Indeed, in the focus groups led by Lagu and Iezzoni, some of the doctors revealed that they view the ADA and the people it protects with contempt. One called people with disabilities “an entitled population.” Another said that the ADA works “against physicians.”

    The Department of Health and Human Services is aware of the issue. In a response to emailed questions, an HHS spokesperson wrote, “While we recognize the progress of the ADA, important work remains to uphold the rights of people with disabilities.” The Office of Civil Rights, the spokesperson continued, “has taken a number of important actions to ensure that health care providers do not deny health care to individuals on the basis of disability and to guarantee that people with disabilities have full access to reasonable accommodations when receiving health care and human services, free of discriminatory barriers and bias.”

    Researchers and advocates told me that the key to improving health care for those with disabilities is addressing it directly in medical education and training. “People with disabilities are probably one of the larger populations” that physicians serve, Salentine said.

    Ryan McGraw, a community organizer with Access Living, helps provide education about treating patients with disabilities to medical schools in the Chicago area. He regularly receives positive feedback from medical students but says the information needs to be embedded in the medical-school curriculum, so it’s not “one and done.”

    In one effort to address the issue, the Alliance for Disabilities in Health Care Education, a coalition of professionals and educators of which McGraw is a member, put together a list of 10 core competencies that should be included in a doctor’s education, including considerations for accessibility, effective communication, and patient-centered decision making.

    Read: What police offers don’t know about the ADA

    One of the simplest solutions might be hanging signs or providing accessible information in exam rooms on patients’ rights. “It’d be there for patients, but it’d be also there as a reminder to the providers. I think that’s a super easy thing to do,” Laura VanPuymbrouck says. Miles says this could be a good start, but “it’s not enough to just give people a little pamphlet that tells you about your rights as a patient.” Although all doctors should be willing and able to care for patients with disabilities, she thinks a registry that shows which providers take certain types of insurance, such as Medicaid, and also have disability accommodations, such as wheelchair-accessible equipment, would go a long way.

    Some advocates have called on the Joint Commission for more than 10 years to require disability accommodations for hospitals that want accreditation. The step could be effective, because accreditation “is extremely important” to hospitals, Lagu says.

    On January 1, 2023, new Joint Commission guidelines will require that hospitals create plans to identify and reduce at least one health-care disparity among their patients. Improving outcomes for people with disabilities could be one such goal. However, Maureen Lyons, a spokesperson for the Joint Commission, adds, “if individuals circumvent the law, standards won’t be any more effective.”

    Finally, Lagu says, “we have to pay more when you are providing accommodations that take time or cost money. There’s got to be some accounting for that in the way we pay physicians.”

    One of the most basic things people with disabilities are asking for is respect. The biggest finding of the 2021 survey, Iezzoni says, is that doctors don’t realize that the proper way to determine what accommodations a facility needs for patients with disabilities is to just ask the patients.

    “I can’t tell you how many times I go to a doctor’s office and I’m talking, but they’re not hearing anything,” Salentine says. “They’re ready to speak over me.”

    [ad_2]

    Emma Yasinski

    Source link