Tuesday, January 31, 2012
The bill would allow us, when considering premium rates proposed by non-profit health insurers, to take into account the large surpluses that the companies have built up in recent years. (Surpluses are not the same thing as reserves. Theres' been some confusion out there on this point.)
These surpluses have grown dramatically over the past decade. The state's three major nonprofit health insurers together now have more than $2.4 billion in surplus.
Meanwhile, the cost of individual health policies more than doubled from 2005 to 2011.
At least 11 other states, including neighboring Oregon, have the authority to consider surpluses when reviewing rates. We think it's time Washington did the same.
Considered the engines of the national health law, state exchanges are online marketplaces designed to make it easier for individuals and small businesses to shop for insurance policies. They will also be one-stop enrollment centers for low-income people who qualify for Medicaid and moderate income individuals who qualify for federal tax credits.
There's a tremendous amount of behind-the-scenes work taking place in Olympia in preparation for these exchanges. Again, from Stateline's article:
One small group of states — led by Maryland, Washington, Oregon, Rhode Island and California — is running significantly ahead of the rest. Statutes have been enacted to create the exchanges and the basic decisions about how to run them have already been made.Our office and Gov. Chris Gregoire have also requested additional exchange legislation in Washington this year.
Monday, January 30, 2012
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|Rainy afternoon. |
When taking your Shabbat walk
and it happens to be raining, you
should always dress appropriately.
|Good old MickyDs. |
Not that I really like McDonalds,
but it is strangely comforting to see,
even if I have to spend 10 min
sounding out the sign.
|Desert anyone? Sometimes the menu is |
only in Hebrew. Sometimes it is in English.
If you are lucky, it will include items like Desert and Coffe.
Michel Anthony James, an independent contractor who was working for State Farm, is believed to have deposited checks from more than 40 policyholders into his own business bank account. State Farm discovered the problems when it audited James' accounts. It subsequently terminated its contract with James.
Based on a subsequent iinvestigation by Insurance Commissioner Mike Kreidler's Special Investigations Unit, James:
• failed to apply premiums to policies,
•wrongly withdrew cash from his premium fund account (which is where those policyholder checks were supposed to go),
•failed to refund overpayments to policyholders,
•and violated contractual agreements with State Farm.
The theft added up to $23,926.87.
On Jan. 13 in Pierce County Superior Court, he pleaded guilty to second-degree theft. He was sentenced to community service, electronic home monitoring and $1,800 in costs and assessments. He has also paid back the misappropriated money.
(Updated Feb. 1 to note that James no longer works for State Farm.)
Because of various assumptions made in the original formulation of the law, the values of E do not translate very well to calories as measured today. What is important is the exponent, and what it means in terms of relative increases in weight. Since the exponent in the equation is 3/4, which is lower than 1, the law essentially states that as body weight increases animals become more efficient from an energy expenditure perspective. For example, the energy expenditure at rest of an elephant, per unit of body weight, is significantly lower than that of a mouse.
The difference in weight does not have to be as large as that between an elephant and a mouse for a clear difference in energy expenditure to be noticed. Moreover, the increase in energy efficiency predicted by the law is independent of what makes up the weight; whether it is more or less lean body mass, for example. And the law is very generic, also applying to different animals of the same species, and even the same animal at different developmental stages.
Extrapolating the law to humans is quite interesting. Let us consider a person weighing 68 kg (about 150 lbs). According to Kleiber's law, and using a constant multiplied to M to make it consistent with current calorie measurement assumptions (see Notes at the end of this post), this person’s energy expenditure at rest per day would be about 1,847 calories.
A person weighing 95 kg (about 210 lbs) would spend 2,374 calories at rest per day according to Kleiber's law. However, if we were to assume a linear increase based on the daily calorie expenditure at a weight of 68 kg, this person weighing 95 kg would spend 2,508 calories per day at rest. The difference of approximately 206 calories per day is a reflection of Kleiber's law.
This difference of 206 calories per day would translate into about 23 g of extra body fat being stored per day. Per month this would be about 688 g, a little more than 1.5 lbs. Not a negligible amount. So, as you become obese, your body becomes even more efficient on a weight-adjusted basis, from an energy expenditure perspective.
One more roadblock to go from obese to lean.
Now, here is the interesting part. It is unreasonable to assume that the extra mass itself has a significantly lower metabolic rate, with this fully accounting for the relative increase in efficiency. It makes more sense to think that the extra mass leads to systemic adaptations, which in turn lead to whole-body economies of scale (). In existing bodies, these adaptations should happen over time, as long-term compensatory adaptations ().
The implications are fascinating. One implication is that, if the compensatory adaptations that lead to a lower metabolic rate are long term, they should also take some time to undo. This is what some call having a “broken metabolism”; which may turn out not to be “broken”, but having some inertia to overcome before it comes back to a former state. Thus, lower metabolic rates should generally be observed in the formerly obese, with reductions compatible with Kleiber's law. Those reductions themselves should be positively correlated with the ratio of time spent in the obese and lean states.
Someone who was obese at 95 kg should have a metabolic rate approximately 5.6 percent lower than a never obese person, soon after reaching a weight of 68 kg (5.6 percent = [2,508 – 2,374] / 2,374). If the compensatory adaptation can be reversed, as I believe it can, we should see slightly lower percentage reductions in studies including formerly obese participants who had been lean for a while. This expectation is consistent with empirical evidence. For example, a study by Astrup and colleagues () concluded that: “Formerly obese subjects had a 3–5% lower mean relative RMR than control subjects”.
Another implication, which is related to the one above, is that someone who becomes obese and goes right back to lean should not see that kind of inertia. That is, that person should go right back to his or her lean resting metabolic rate. Perhaps Drew Manning’s Fit-2-Fat-2-Fit experiment () will shed some light on this possible implication.
A person becoming obese and going right back to lean is not a very common occurrence. Sometimes this is done on purpose, for professional reasons, such as before and after photos for diet products. Believed it or not, there is a market for this!
- Calorie expenditure estimation varies a lot depending on the equation used. The multiplier used here was 78, based on Cunningham’s equation, and assuming 10 percent body fat. The calorie expenditure for the same 68 kg person using Katch-McArdle’s equation, also assuming 10 percent body fat, would be about 1,692 calories. That would lead to a different multiplier.
- The really important thing to keep in mind, for the purposes of the discussion presented here, is the relative decrease in energy expenditure at rest, per unit of weight, as weight goes up. So we stuck with the 78 multiplier for illustration purposes.
- There is a lot of variation across individuals in energy expenditure at rest due to other factors such as nonexercise activity thermogenesis ().
Sunday, January 29, 2012
• Avoid skipping meals earlier in the day. Skipping breakfast may lead to overeating later in the day when you become famished and have tons of foods at your disposal.
• Get an adequate amount of sleep the night before. Lack of sleep will leave your body searching for energy, making it harder to resist fattening foods.
• Drink plenty of water. This will not only fill your belly, but help curb cravings. Limit alcohol to avoid too many extra calories. If you choose to have a few, alternate alcoholic beverages with sparkling water with lemon.
• Avoid carbonated beverages. These will bloat you, interfering with your body's ability to signal when you are full. The carbonation will also interfere with proper digestion.
• Prepare baked foods or fattening dishes using natural sweeteners or lower-calorie and lower-fat versions of ingredients.
• Eat slowly and wait at least 15 minutes before going back for a second helping. This gives the body enough time to feel satiated.
• Commit to working out the next day by signing up for a class or a run the next morning. You will be less likely to over do it if you know you have to get up early and run a 5K. The workout will also balance over consumption and burn calories!
• Enjoy your food! We spend so much time avoiding certain foods or viewing food as the enemy that we forget it can be pleasurable. We may worry that once we eat a food that brings us pleasure we won't be able to stop. The answer is controlled eating rather than out-of-control eating. Slow down and be aware of the taste, texture, temperature, and smell, and savor every bite!
Keep it Fresh!
Saturday, January 28, 2012
What YOU can do:
Take a good hard look at what you are drinking each day, figure out where the sources of added sugars are and think about how to cut back on that. Plan ways to substitute sugary foods in your diet with things like sweet vegetables, fruits or herbal teas.
1. Put down the can. Soft drinks are the biggest culprit! Soft drinks by far, followed by candy, cakes, cookies and pies. With about 8 teaspoons of added sugar, a regular 12-ounce soft drink will put most over the recommended daily limit. Keep in mind, it DOES NOT make it ok if they are diet drinks. Artificial sweeteners (such as Splenda, Equal, Sweet & Low, etc.) are even more toxic than the refined sugars that are in regular sugary drinks!
2. Drink water. Replacing carbonated soft drinks with water will cut a lot of your sugar intake, and the benefits don't stop there. Drinking two glasses of water before a meal may encourage the stomach to feel full more quickly, so you don't eat as much. Lots of the time you may have a sweet craving because your body is dehydrated, so drink up!
3. Drink real fruit juice. Juice can have as many calories as soda, but it has far more to offer in the way of nutrients. This presents a dilemma -- you want the vitamins and antioxidants without all the extra sugar. The safest bet: Look for 100% fruit juice. Steer clear of juice drinks that have added sweeteners. Look for the percent of real juice, noted on the nutritional label. You can also slash sugar intake by drinking water with a splash of juice. Feel free to squirt some lemon, lime or orange slices into your water for a healthy, yet flavorful drink!
4. Try coconut water! Sports and energy drinks are sugar bombs like soda. Although they contain electrolytes which are great for hydrating the body, its still smarter to stay hydrated with water rather than sports drinks. A wonderful alternative to sports drink is coconut water. It's a natural isotonic beverage, with the same level of electrolytic balance as we have in our blood. It contains more potassium than most sports or energy drinks and has less sodium. It's the fluid of life, so to speak!
5. Enjoy a cup of tea. Herbal teas can be not only delicious, but hydrating at the same time. There is a wide variety of flavorful herbal teas that will satisfy your sweet tooth. Right now I’ve been enjoying Yogi Tea’s Mayan Cocoa Spice made with cinnamon bark. It has low caffeine and plenty of rich chocolate flavor! It’s a must try!Keep it fresh!
Friday, January 27, 2012
I have explained in various posts why this idea does not appear to be correct (1, 2, 3), and why, after extensive research, the insulin hypothesis of obesity lost steam by the late 1980s. However, I recently came across two experiments that tested the hypothesis as directly as it can be tested-- by chronically increasing circulating insulin in animals and measuring food intake and body weight and/or body fatness. If the hypothesis is correct, these animals should gain fat, and perhaps eat more as well.
Read more »
Cash B. Knott, 46, pleaded guilty Jan. 13 in Pierce County Superior Court.
On Nov. 6th, less than a month after getting coverage from Progressive Direct Insurance Co. for his 1992 Ford Ranger pickup, Knott filed a $5,674 insurance claim with Progressive. He said someone had scratched the paint, stolen his chrome wheels and tires, and stolen his navigation and entertainment system, 1,000 watt amplifier and other electronic components.
He provided Progressive with a Sept. 2 stereo shop invoice for $4,547.84 worth of stereo equipment, a copy of his check, and a bank statement showing the withdrawal from his checking account.
The problem: When contacted by an insurance adjuster, the stereo shop said it had no record of such a purchase. All they could find was that Knott had bought an amplifier -- for $109 -- on Sept. 2.
Insurance Commissioner Mike Kreidler's Special Investigations Unit obtained a search warrant for Knott's bank records. The bank found no checks written to the stereo shop, and none whatsoever for $4,547.84.
He's slated for sentencing on Feb. 17th. The standard range for the charges are 22 to 29 months in prison.
According to the III, your odds of dying from:
- A car accident: 1 in 303.
- Being shot: 1 in 306.
- Falling down the stairs: 1 in 2,018.
- An airplane crash: 1 in 7,032.
- Falling off a ladder: 1 in 8,912
- A lightning strike: 1 in 84,079.
See the link above for more examples.
Thursday, January 26, 2012
- A debt-plagued Arizona homeowner torched his home for $440,000 in insurance money -- and killed a witness and the witness' family. He got 14 years in prison for the insurance fraud, and the death sentence for the murders.
- A Rhode Island radio DJ who wanted to upgrade her home and pool had several friends simulate storm damage to her home -- smashing a hole in her roof with a tree limb, messing up the pool, etc. The problem: The weather was fair and in the 70s that day. And one of the DJ's accomplices was caught on an unrelated federal wiretap bragging about the job.
- Another home-arson case involved a California couple who hired a man to burn down their home. The man used a lot of gasoline, leading to a blast that left him horribly burned. He died later that day. The couple went to prison.
- There are several others, but we'll end with what's probably the strangest case. A mortuary workers and medical worker faked the death of a man who'd never existed. There was even a grave. And a funeral service. Using forged documents, the workers and accomplices had taken out $950,000 in life insurance policies on the fictitious man.
Wednesday, January 25, 2012
I encourage you to celebrate the new year by taking the time to think about what you are grateful for and express that gratitude. Be truly thankful for the bounty of food before you and recognize that it should not be taken for granted. Be thankful for the people around you and celebrate with family, friends or neighbors. Be thankful for your health and your body’s ability to heal itself. Be thankful for all the things in your life that make you happy and take the time to reevaluate those that don’t.
There are so many things that nourish our bodies, aside from what choices we make concerning food. When all the different aspects of our lives are in balance, this is when our body, mind and soul thrive and we are at our healthiest. Think about all of the different areas of your life…. your relationships with friends and family, your romantic relationship, your career path, your home and physical surroundings, the amount of physical activity you make time for….. and recognize imbalances. What areas would you like to change, where is there room for improvement? How can you create the exact life that you want to live, in the exact world that you want to live it in?
We have the power to create the life we want and we have the power to change the things in our lives that we are unsatisfied with, but we all too often let fear hold us back. All year long, be thankful for the areas in which you are satisfied, but also take steps towards changing the rest. Set goals for yourself. Write them down and hold yourself accountable for reaching them.
- Take out a piece of paper and write down your life goals for where you want to be or what you want to accomplish 1 month from now, 6 months from now, and 1 year from now.
- On another piece of paper make three lists of the steps you need to take to make each of those goals attainable.
- Use a journal to keep track of your goals and your progress. Check off each step as you accomplish it and update them as your goals change.
- Express gratitude towards the people or opportunities that helped you reach each goal. Below, you will find ten tips on how to do just that!
10 Ways to Express Gratitude
Wake up with gratitude. Before you even get out of bed each morning, say one thing that you are grateful for.
Write a quick "Thank You" note or card to someone who has done something nice, or simply been there for you.
Be generous with affection. Everyone loves hugs!!
Practice random act of kindness. They will make you feel good and put a smile on someone else's face as well.
Give back. Donate time, money,
goods to those less fortunate.
Acknowledge jobs well done. Even something as simple as letting a manager at your local coffee shop how great your favorite barista is, can make someone's day. Who knows, maybe he/she will receive a bonus as a result.
Write down 10 things you like about yourself. Write down 10 things you like about someone else and send it to them.
Let go of anger and resentment and forgive someone towards whom you hold a grudge.
Pray or meditate. Taking the time to collect your thoughts will help you find balance and be more aware of the things that you are grateful for.
Make someone a healthy meal. The way to everyone's heart is through their stomach. A delicious homemade meal full of love and gratitude will be warmly accepted.
Keep it Fresh!
The question of whether to get long-term care insurance bedevils consumers and their advisers. Unlike medical insurance, it is intended primarily to cover people who need assistance with so-called activities of daily living -- for example, the care of a dementia patient or someone recovering from a broken hip. It can be expensive: Premiums range from $1,000 to $5,000 a year, depending on the age, sex and health of the purchaser as well as the extent of the coverage. And policy details can be confusing.
Even advocates acknowledge that it isn't for everyone. Jesse Slome, executive director of the American Association for Long-Term Care Insurance, an industry group, sums it up well: "Long-term care is a universal issue facing all Americans who are getting older. But long-term-care insurance is not a universal solution."Many people think that their health insurance will cover long term care, but most don't. Nor do Medicare or Medicare supplemental policies. Medicaid will pay, but to qualify for Medicaid, your assets must dwindle away to almost nothing.
In recent years, we've received numerous complaints about the cost of the policies. Long term care insurance is a fairly new product, with many companies not offering it until the early 1990s. As a result, they had little experience to base their prices on, and early policies were priced significantly lower than they should have been, based on how the cost of claims and the fact that -- unlike life insurance, for example -- few people cancel the policies.
As a result, most long-term care insurers have bumped up their premiums sharply in the past few years -- in some cases 40 percent or more -- angering customers who signed up for policies at relatively low cost years ago. This is a problem across the country. Again, from the article:
"It's probably the most frequent complaint I hear," says (Kansas Insurance Commissioner Sandy) Praeger, who heads the National Association of Insurance Commissioners' health and managed care committee. "The problem is, the older policies weren't priced right to begin with. Companies expected about 8 percent of customers to stop paying their premiums, when, in fact the lapse rate is closer to 2 percent." That meant the insurers had to cover more beneficiaries than they expected at a time when the economic downturn has meant less returnon their investments.
Praeger acknowledges that rate increase requests have posed a dilemma for insurance commissioners. "If we don't give them the rate increase they need, the insurance carriers could become financially impaired, and that doesn't help people," she says. In fact, in recent years, a number of companies have stopped selling policies. As a result, she adds, it's hard to turn the increases down.
Indiana-based Unicare Life and Health Insurance Co. has agreed to pay the fine.
Between mid-2004 and mid-2009, Unicare sold thousands of medical insurance policies to students at community colleges, technical schools, colleges and universities across Washington state. Insurance Commissioner Mike Kreidler’s office later determined that there were substantial problems with the coverage. Among them:
• For more than six years, the company used unapproved methods to set its rates.
• Unicare continued to wrongly cite a policy exclusion for 5 years after the law had changed to ban insurers from using the exclusion.
• Unicare allowed unlicensed insurance agents to market and sell the policies. The primary company marketing the policies was not licensed to do business in Washington until June 2009. At that point, it had been selling the policies for four years.
The company was unable to respond to Kreidler’s requests for supporting documentation on rates at specific colleges, saying that the documents were prepared by employees who no longer worked there.
Fines collected by the insurance commissioner’s office do not go to the agency. The money is deposited in the state’s general fund to pay for other state services.
The policies included international students at the University of Washington, Washington State University, Bellevue Community College, Seattle Pacific University, Shoreline Community College, Tacoma Community College and South Puget Sound Community College, among others.
- Do you have experience working with people who have concerns and goals similar to mine? If so, have you had success with them?
- What therapeutic approaches do you use?
- How many sessions do you average per client?
- Do you monitor progress and outcomes? Tell me about it.
- What do you do if a particular therapeutic approach is not helping?
Tuesday, January 24, 2012
Monday, January 23, 2012
These are the factors I'm aware of that can contribute to insulin resistance, listed in approximate order of importance. I could be quite wrong about the order-- this is just my best guess. Many of these factors are intertwined with one another.
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Often the diets compared have different macronutrient ratios, which end up becoming the focus of the comparison. Many consider Sacks and colleagues’ conclusion, based on yet another diet comparison study (), to be the most consistent with the body of evidence as a whole: “Reduced-calorie diets result in clinically meaningful weight loss regardless of which macronutrients they emphasize”.
I think there is a different conclusion that is even more consistent with the body of evidence out there. This conclusion is highlighted by the findings of almost all diet studies where participants were followed for more than 1 year. But the relevant findings are typically buried in the papers that summarize the studies, and are almost never mentioned in the abstracts. Take for example the study by Toubro and Astrup (); Figure 3 below is used by the authors to highlight the study’s main reported finding: “Ad lib, low fat, high carbohydrate diet was superior to fixed energy intake for maintaining weight after a major weight loss”.
But what does the figure above really tell us? It tells us, quite simply, that both diets succeeded at first, and then eventually failed. One failed slightly less miserably than the other, in this study. The percentage of subjects that maintained a weight loss above 25 kg (about 55 lbs) approached zero after 12 months, in both diets. This leads us to the conclusion below, which is always missing in diet studies even when the evidence is staring back at us. This is arguably the conclusion that is the most consistent with the body of evidence out there.
All diets succeed at first, and eventually fail.
In using the terms “succeed” and “fail” I am referring to the diets’ effects on the majority of the participants. This is in fact better demonstrated by the figure below, from the same study by Toubro and Astrup; it is labeled as Figure 2 there. Most of the participants at a certain weight, lose a lot of weight within a period of 1 year or so, and after 2 years (see the two points at the far right) are at the same original weight again. What is the average time to regain back the weight? From what I’ve seen in the literature, all the weight and some tends to be regained after 2-3 years.
The regained weight is not at all lean body mass. It is primarily, if not entirely, body fat. In fact, many studies suggest that those who diet tend to have a higher percentage of body fat when they regain their original weight; proportionally to how fast they regain the weight lost. Since the extra body fat tends to cause additional problems, which are compounded by the dieting process’ toll on the body, those dieters would have been slightly better off not having dieted in the first place.
Guyenet and Schwartz have recently authored an article that summarizes quite nicely what tends to happen with both obese and lean dieters (). Take a look at Figure 2 of the article below. The obese need to lose body fat to improve health markers, and avoid a number of downstream complications, such as type 2 diabetes and cancer (). Yet, with very few exceptions, the obese (and even the overweight) remain obese (or overweight) after dieting; regardless of the diet.
So what about those exceptions, what do they do to lose significant amounts of body fat and keep it off? Well, I rarely use myself as an example for anything in this blog, but this is something with which I unfortunately/fortunately have personal experience. I was obese, lost about 60 lbs of weight, and kept it off for quite a while already (). Like most of the formerly obese, I can very easily gain body fat back.
But I don’t seem to be gaining back the formerly lost body fat, and the reason is consistent with some of the studies based on data from the National Weight Control Registry, which stores information about adults who lost 30 lbs or more of weight and kept it off for at least 1 year (). I systematically measure my weight, body fat percentage, and a number of other variables; probably even more than the average National Weight Control Registry member. Based on those measurements, I try to understand how my body responds in the short and long term to stimuli such as different exercise, types of food, calorie restriction, sleep patterns etc.
And I act accordingly to keep any body fat gain from happening; by, for example, varying calorie intake, increasing exercise intensity, varying the types of food I eat etc. With a few exceptions (e.g., avoiding industrial seed oils), there is no generic formula. Customization based on individual responses and cyclical patterns seems to be a must.
Looking back, it was relatively easy for me to lose all that fat. This is consistent with the studies summarized in this post; all diets that rely on caloric reduction work marvelously at first for most people. The really difficult part is to keep the body fat off. I believe that this is especially true as the initial years go by, and becomes easier after that. This has something to do with initial inertia, which I will discuss soon in a post on metabolic rates and their relationship with overall body mass.
For people living in the wild, I can see one thing working in their favor. And that is not regular starvation; sapiens is too smart for that. It is laziness. Hunger has to reach a certain threshold for people to want to do some work to get their food; this acts as a natural body composition regulator, something that I intend to discuss in one of my next posts. It seems that people almost never become obese in the wild, without access to industrial foods.
As for living in the wild, in spite of the romantic portrayals of it, the experience is not as appealing after you really try it. The book Yanomamo: The Fierce People () is a solid, if not somewhat shocking, reminder of that. I had the opportunity to meet and talk at length with its author, the great anthropologist Nap Chagnon, at one of the Human Behavior and Evolution Society conferences. The man is a real-life Indiana Jones ().
In the formerly obese, the body seems to resort to “guerrilla warfare”, employing all kinds of physiological and psychological mechanisms, some more subtle than others, to make sure that the lost fat is recovered. Why? I have some ideas, which I have discussed indirectly in posts throughout this blog, but I still need to understand the whole process a bit better. My ideas build on the notion of compensatory adaptation ().
You might have heard some very smart people say that you do not need to measure anything to lose body fat and keep it off. Many of those people have never been obese. Those who have been obese often had not cleared the 2-3 year “danger zone” by the time they made those statements.
There are many obese or overweight public figures (TV show hosts, actors, even health bloggers) who embark on a diet and lose a dramatic amount of body fat. They talk and/or write for a year or so about their success, and then either “disappear” or start complaining about health issues. Those health issues are often part of the “guerrilla warfare” I mentioned above.
A few persistent public figures will gain the fat back, in part or fully, and do the process all over again. It makes for interesting drama, and at least keeps those folks in the limelight.