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    The Socio-Economic Causes of Obesity, by Charles L. Baum and Shin-Yi Chou (NBER)

    An increasing number of Americans are obese, with a body mass index of 30 or more. In fact, the latest estimates indicate that about 30% of Americans are currently obese, which is roughly a 100% increase from 25 years ago. It is well accepted that weight gain is caused by caloric imbalance, where more calories are consumed than expended. Nevertheless, it is not clear why the prevalence of obesity has increased so dramatically over the last 30 years.

    We simultaneously estimate the effects of the various socio-economic factors on weight status, considering in our analysis many of the socio-economic factors that have been identified by other researchers as important influences on caloric imbalance: employment, physical activity at work, food prices, the prevalence of restaurants, cigarette smoking, cigarette prices and taxes, food stamp receipt, and urbanization. We use 1979- and 1997-cohort National Longitudinal Survey of Youth (NLSY) data, which allows us to compare the prevalence of obesity between cohorts surveyed roughly 25 years apart. Using the traditional Blinder-Oaxaca decomposition technique, we find that cigarette smoking has the largest effect: the decline in cigarette smoking explains about 2% of the increase in the weight measures. The other significant factors explain less.

    Depression Care Following Psychiatric Hospitalization in the Veterans Health Administration, by Paul N. Pfeiffer, Dara Ganoczy, Nicholas W. Bowersox, John F. McCarthy, Frederic C. Blow, and Marcia Valenstein (AJMC)

    Objectives: To assess quality of depression care during the high-risk period following a psychiatric hospitalization.

    Study Design: Retrospective administrative data analysis.

    Methods: Using Veterans Health Administration (VHA) administrative data, we assessed mental health follow-up within 7 and 30 days of psychiatric hospitalizations for major depression from 2004 to 2008. Adequate antidepressant medication coverage and number of psychotherapy visits were assessed within 90 days of discharge. Multivariable logistic regression was used to identify patient demographic and clinical characteristics associated with each quality indicator.

    Results: Of the 45,587 patients discharged from a psychiatric inpatient stay with a diagnosis of major depressive disorder, 39.4% and 75.8% received an outpatient visit within 7 and 30 days of discharge, respectively; 58.7% of patients received adequate antidepressant coverage (72 of 90 days) and 12.9% received adequate psychotherapy encounters (8 visits). Receipt of outpatient mental health visits and of adequate psychotherapy were less likely among patients who were male, aged <35 or >65 years, had >3 major general medical comorbidities, lived >30 miles from a VHA clinic, or whose hospital length of stay was <7 days. Patients with comorbid substance use disorders were less likely to receive adequate antidepressant treatment.

    Conclusions: To optimize evidence-based depression care after a psychiatric hospitalization, health systems might increase receipt of psychotherapy by considering potential barriers related to age, medical condition, and distance. Patients with comorbid substance use disorders or their providers may need additional services to support antidepressant treatment.

    Addressing the Shortage of Kidneys for Transplantation: Purchase and Allocation through Chain Auctions, by Lara Rosen, Aidan R. Vining, and David L. Weimer (JHPPL). A commentary and response follows this article in the journal. All are gated.

    Transplantation is generally the treatment of choice for those suffering from kidney failure. Not only does transplantation offer improved quality of life and increased longevity relative to dialysis, it also reduces end-stage renal disease program expenditures, providing savings to Medicare. Unfortunately, the waiting list for kidney transplants is long, growing, and unlikely to be substantially reduced by increases in the recovery of cadaveric kidneys. Another approach is to obtain more kidneys through payment to living “donors,” or vendors. Such direct commodification, in which a price is placed on kidneys, has generally been opposed by medical ethicists. Much of the ethical debate, however, has been in terms of commodification through market exchange. Recognizing that there are different ethical concerns associated with the purchase of kidneys and their allocation, it is possible to design a variety of institutional arrangements for the commodification of kidneys that pose different sets of ethical concerns. We specify three such alternatives in detail sufficient to allow an assessment of their likely consequences and we compare these alternatives to current policy in terms of the desirable goals of promoting human dignity, equity, efficiency, and fiscal advantage. This policy analysis leads us to recommend that kidneys be purchased at administered prices by a nonprofit organization and allocated to the transplant centers that can organize the longest chains of transplants involving willing-but-incompatible donor-patient dyads.

    How Much Savings Can We Wring from Medicare? by Michael Chernew, Dana Goldman, and Sarah Axeen (NEJM)

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    • “It is well accepted that weight gain is caused by caloric imbalance, where more calories are consumed than expended.”

      It may be well accepted, but it is wrong. (It is also increasingly less well accepted.) Please see Gary Taubes “Good Calories, Bad Calories” for the background. But in a nutshell, refined carbohydrates increase blood sugar levels, which drives insulin secretion, which in turn is responsible for storing fat in fat cells. Put aside what is (increasingly less) “well accepted” and look at the microbiology. (The “Calorie Imbalance” argument is surprisingly lacking in a microbiological model, as you will discover if you read Taubes.)

      This adds a new and simpler economic model for obesity: carbs are cheaper. Rice, pasta, breads, etc., are cheaper than meat, fish, eggs and so on. Which is why the poor, who are far more likely to engage in calories-expending manual labor, are more obese than the more well off. With an incorrect analysis of what actually makes us fat, the economic analysis attempted in the paper is of lmited value.

      • Could not agree with you more. A calorie is not a calorie. What happened thirty years ago is that faulty data (see Ancel Keys) drove an erroneous public health recommendation that everyone eat low fat and high carbs. Oops!!