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AMA Sues HHS

Home Health Care Revives House Calls for Doctors

Technology helps in the house calls. Some travel to patients with an X-ray machine, a blood-gas analyzer, an EKG and a cardiac-output machine.

House calls faded from the health care system 30 years ago when Medicare slashed fees for home visits. Managed care doesnít have enough clear-cut data on savings from house calls to promote them. There will be more demand for house calls as the population ages. An estimated 2 million senior citizens were physically unable to leave their homes in 1999.

Recent change sin Medicare payments have raised payments for at-home care by doctors. The San Diego house-call services have begun to turn a small profit and the company sees more growth ahead. (Texas Innovator)

Nurse Practitioners May Use More Health Care Resources Than Physicians

Arlington Memorial Hospital Begins $17 Million Renovation and Construction Project

Closings

Baylor Health Care System stated it is closing its Ennis hospital this month. Closure of the 48-bed medical center, southeast of Fort Worth, will require Ennis patients to travel 26 mils to Dallas or 17 miles to Waxahachie and will removed the only emergency room from a community of 17,000 residents, according the December 6, 1999, Fort Worth Star-Telegram. Ennis lost over $14 million since 1992.

Disabled Persons to Retain Medicare/Medicaid Coverage After Return to Work

FDA Announces New Internet Website for Consumers

Consumers who suspect that a Website is illegally selling human or animal drugs, medical devices, biological products, foods, dietary supplements or cosmetics over the Web can also fill out an electronic complaint form provided at this site, and e-mail it directly to the FDA.

IOM Report Recommends Medicare Coverage for Nutritional Counseling

Two Managed Care Companies Fined by ERST

HCFA Says Medicaid Benefits are being Illegally Denied

New Jersey HMO Will Cover Costs Associated with Cancer Treatment Trials

Texas Cancer Care Restructures Relationship with OnCare

"Texas Cancer Care affiliated with OnCare in 1996, anticipating the relationship would produce cost savings and generate more favorable contracts from health care payers. Neither of these benefits have been realized," said Dr. Jordan.

"The business world is aggressively forcing itself into medicine," he said. "This experience confirms that high-quality cancer management and patient care demands an intensive personal commitment from the physician, nursing and supportive staff. That ideal is the fundamental path which we will continue to follow."

During the past three years, Texas Cancer Care has been a principal beta test site for the development of KnowChart, an electronic medical record system considered one of the most advanced information platforms for oncology. Texas Cancer Care will continue to participate in its development.

"This type of high-level information technology will dramatically enhance our ability to collect and analyze information about cancer, while coordinating focus of research protocols," noted Dr Jordan. He added, "Substantive progress in treating cancer is a product of a partnership between the patient, the physician, research and technology. Our new structure will enable us to maximize the benefits of that partnership. The restructuring will be transparent to patients, and services will continue without interruption."

Pressure Mounts to Reduce Medical Errors

Why Americans are Hospitalized and What it Costs ñ Government Report

The report, which is based on 1996 data, is the latest in a series of statistical publications from AHCPR showing why Americans are hospitalized, how long they stay in the hospital, the procedures they undergo, and the charges for their stays.

According to the report, the most expensive conditions, or diagnoses, treated in U.S. hospitals in 1996, were spinal cord injury ($56,800), infant respiratory distress syndrome ($56,600), low birthweight ($50,300), leukemia ($46,700) and heart valve disorders ($45,300). The figures are average charges for the entire stay.

Overall, patients stayed in the hospital an average of five days. But stays involving premature birth, with problems such as low birthweight and slow growth of the fetus, averaged 23 days. Stays because of infant respiratory distress syndrome averaged 22 days, and patients with spinal cord injuries remained hospitalized an average of 16 days.

The estimates are based on all payer data from AHCPRís Nationwide Inpatient Sample, which approximates a 20-percent sample of U.S. community hospitals. The database is part of the Healthcare Cost and Utilization Project, a federal-state-industry partnership to make high-quality hospital data available for research purposes.

Hospital Inpatient Statistics, 1996 (AHCPR 99-0034) is available from the AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, Maryland 20907-8547 (phone: 800-358-9295).

(Why Americans are Hospitalized and What it Costs Detailed in New Government Report. Press Release, August 26, 1999. Agency for Health Care Policy and Research, Rockville, MD)

Selected Facts and Figures about Texas

• Number 2 in births per 1,000 population in 1998 (17.3)
• Number 5 in percent of mothers receiving late or no prenatal care in 1997 (5.1%)
• Number 8 in Medicare payment per hospital day in fiscal 1997 ($2,382)
• Number 10 in percent of births to teenage mothers in 1997 (16.1%)
• Number 21 in federal share of welfare and Medicaid in 1998 (62.3%)
• Number 22 in Workers' Compensation temporary disability payments in 1998 ($508)
• Number 24 in percent of population that reported not being physically active in 1996 (27.9%)
• Number 31 in infant mortality rate in 1997 (6.3 deaths per 1,000 live births)
• Number 32 in Workers' Compensation benefit payment per employee in 1995; and percent of adults who smoked in 1997 (22.6)
• Number 39 in doctors per 100,000 population in 1997 (212)
• Number 46 in percent of population 65 or older in 1997 (10.1%)

Texas HIV/STD Community Resource Directory Available

The CRD is a 280-page guide listing Texas HIV/STD service providers, community based organizations, testing sites, hotline numbers, and other informational and educational resources.

The CRD is free of charge, although orders should be limited to 10 copies. To order, contact the Texas Department of Health Warehouse facility in writing (telephone or walk-up order are not accepted) at:

Texas Department of Health Warehouse
Literature and Forms
1100 West 49th Street
Austin, TX 78756
FAX: (512) 458-7707

When ordering, include the stock number (4-113), quantity (maximum 10), your name, and your shipping address.

Problem Nursing Homes to Face Immediate Sanctions

To encourage sanctions to be imposed more quickly, states also received expanded authority to notify nursing homes when they would be denied payments for new admissions and other sanctions for failing to meet health and safety requirements. In addition, HCA provided guidance for the use of a new enforcement tool that allows fines of up to $10,000 for each serious incident that threatens residents' health and safety. In the past, fines could only be based on the number of days that a nursing home failed to meet federal requirements.

This past year, HCF has taken steps to strengthen the state inspection and enforcement process. Among them, 1) state inspectors were instructed to increase their focus on preventing bedsores, malnutrition and abuse in nursing homes; 2) HCFA established a new requirement for states to focus on complaints alleging harm to residents and conduct investigations within 10 days, and states will continue to be required to investigate complaints alleging the most serious violations within two days; 3) states now must conduct more frequent inspections of nursing homes that have repeated serious violations without decreasing inspections of other facilities; and 4) state inspectors must now make the timing of inspections unpredictable and must conduct some visits on weekends, early mornings and nights to look for quality, safety and staffing problems at those times.

OSHA Revises Compliance Directive for Bloodborne Pathogens

The new directive emphasizes the importance of an annual review of the employer's bloodborne pathogens programs and the use of safer medical devices, without advocating the use of one device over another. It also highlights basic work practices, personal protective equipment, and administrative controls. The agency will review the 1991 standard on occupational exposure to bloodborne pathogens with regard to possible revision. The directive can be found at: http://www.osha.gov.

Compliance Guidelines for Medicare+Choice Organizations

The following are some of the OIG's areas of concern:

The OIG and HCFA strongly discourage M+C organizations from using physicians as marketing agents for several reasons:

1. When a physician act outside his or her traditional role as care provider, the physician's patients may be confused as to when the physician is acting as an agent of the plan, and when the physician is acting in his or her role as a fiduciary to act in the best interests of the patient;
2. A physician's knowledge of a patient's health status increases the potential for discriminating in favor of Medicare beneficiaries with positive health status when acting as a marketing agent;
3. Physicians may not be fully aware of membership plan benefits and costs; and
4. Physicians may not be the best source of membership information for their patients. Therefore, the organization should develop policies to ensure that any provider promotional activities are conducted in accordance with HCFA guidelines (which allow, e.g., the distribution of health plan brochures [exclusive of applications] at a health fair or in their own offices).

1. Medical condition (including mental illness);
2. claims experience;
3. receipt of health care;
4. medical history;
5. genetic information;
6. evidence of insurability; and
7. disability.

Disenrollment: Each Medicare+Choice organization must implement policies to ensure that inappropriate disenrollment does not occur. Such policies should include clarification of when it is appropriate for medical personnel to discuss the concept of disenrollment. Generally speaking, the OIG believes it would be inappropriate for medical personnel to initiate discussion of disenrollment or to promote disenrollment (when the topic is initiated by the enrollee), except in the rare circumstance where the Medicare+Choice organization cannot or does not provide the covered medical items or services needed by the patient.

Payment Incentive Plans (PIP): Any PIP operated by a Medicare+Choice organization must comply with the following requirements: First, it may make no payments to physicians (such as offerings of monetary value, including, but not limited to, stock options or waivers of debt) to reduce or limit medically necessary services furnished to any particular enrollee. Second, if the PIP puts a physician o physician group at "substantial financial risk" for referral services, the Medicare+Choice organization must 1) survey current and previously enrolled members to assess access to, and satisfaction with, the quality of services; and 2) assure that there is adequate and appropriate stop-loss protection. Finally, Medicare+Choice organizations must disclose to HCFA certain information regarding their PIPs. These disclosure requirements apply to direct contracting arrangements, as well as subcontracting arrangements.

(American Osteopathic Association Department of Government Relations)

Medicare Announces New Payment System for Home Health

The new system will complete the transition from the pre-BBA cost-based system.

Under the proposed system:

• Medicare would pay home health agencies for each covered 60-day episode of care. Beneficiaries could receive an unlimited number of episodes of care.

• Medicare would pay home health agencies at a higher rate to care for those beneficiaries with greater needs. Nurses and other clinical workers at Medicare-certified agencies already use a comprehensive, standardized tool to assess the needs of patients. Payment rates would be based on relevant data from the assessment.

• Agencies would receive additional payments for an individual beneficiary if the costs of that care were significantly higher than the specified payment rate. Such "outlier" payments would account for the unusual needs of specific beneficiaries.

• The payment system would use national payment rates, with adjustments to reflect area wage differences and the intensity of care required by each beneficiary.

• The payments would encompass Medicare-covered home-health services for a 60-day episode of care, including skilled nursing and home-health aide visits, covered therapy, medical social services and supplies.

• Medicare would pay home health agencies separately for the medically necessary durable medical equipment provided under the home-health plan of care.

• Payment rates would be adjusted to reflect significant changes in a patient's condition during each Medicare-covered episode of care.

• Medicare would require agencies to provide at least five visits to beneficiaries to receive the full payment for each Medicare-covered episode of care. For fewer visits, Medicare would rely on a different methodology to ensure appropriate payments.

The BBA followed the period from 1990 to 1997 during which Medicare payments to home health agencies grew from $3.7 billion to $17.8 billion, and the average number of visits per beneficiary doubled from 36 to 73.

Medicare has paid hospitals under a prospective payment system since 1983. Medicare began to pay nursing homes under a prospective payment system in 1998. The BBA also requires HCFA to implement prospective payment systems for hospital outpatient services and for rehabilitation hospitals.

AOHA Federal Update

• Following a partisan and relatively unproductive year, Congress gave health care providers early cause for Thanksgiving, passing legislation November 19 that restores $16 billion in Medicare payments cut by the Balanced Budget Act of 1997 (BBA). Part of a $385 billion spending bill that funds the District of Columbia and seven government agencies, the package increases Medicare payments to hospitals, skilled nursing facilities, home health agencies, Medicare+Choice plans, and other health care providers. The President signed the bill into law on November 29.

• For teaching hospitals, the legislation includes a two-year freeze in BBA-mandated indirect medical education (IME) cuts, providing an estimated $600 million in relief. Under the package, the IME adjustment factor will be frozen at 6.5% in FY 2000, then reduced to 6.25% in FY 2001 and 5.5% in FY 2002 and subsequent years. Claims processed in the first half of FY 2000 will be paid at the BBA-established 6% level, with a special aggregate adjustment equal to the difference after April 2000 to avoid reprocessing and Y2K concerns.

• Osteopathic graduate medical education programs likely will benefit from changes to direct graduate medical education (DGME) payments as well. Beginning in FY 2001, the "giveback" provisions partially address wide disparities in teaching hospitals' per-resident amounts, setting minimum DGME payment at 70% of a geographically adjusted national average. Hospitals at or below 70% will be increased to the minimum and updated annually for inflation. Those over 140% of the average will be frozen at current levels in FYs 2001 and 2002 and updated by the consumer price index minus 2% in FYs 2003-2005. Hospitals with per-resident amounts between 70 and 140% will continue to be paid at current levels, updated for inflation. Up to 300 teaching hospitals can expect to receive increases in DGME payment under the new payment formula.

• Several additional changes provide flexibility for rural and non-rural teaching programs. Hospitals located in rural areas will be permitted to increase their resident limits by 30% for both DGME and IME purposes. Non-rural facilities operating separately accredited rural training programs in rural areas or programs with integrated rural tracks will be allowed to adjust their resident counts for cost reporting periods beginning April 1, 2000. When residents are absent on maternity, disability, or similar approved leave, hospitals will be permitted to increase primary care resident counts in their base year limits by up to three full time equivalent (FTE) residents. Qualified non-rural hospitals will be allowed to reclassify as rural for purposes of designation as Critical Access Hospitals, Sole Community Hospitals, or Rural Referral Centers.

• Teaching hospitals also will benefit from a slow-down in reductions to disproportionate share hospital (DSH) payments and a number of outpatient PPS reforms, including a three and one-half year payment floor with "targeted incentives" to reward hospitals that increase their efficiency as quickly as possible, while protecting them from large payment losses.

• Congress has returned from its recess to a host of unresolved issues. Among the unfinished business: patients' rights, Medicare reform, comprehensive medical privacy protection, tax cuts, and increased access for the uninsured, all ripe for legislative scrutiny this year. Given the 2000 elections, whether heated debate is likely to result in concrete action is anybody's guess.

10 Years Ago in the Texas D.O.

• The Texas Department of Health reported that Texas continued to lead the nation in the number of reported measles cases for 1989. According to the TDH, Texas had reported 3,099 cases of measles as of October 31, 1989.

• The Commerce Department estimated that the U.S. would spend $661 billion on health care in 1990, up an estimated 10.4 percent from 1989. In 1989, the nation spent close to $600 billion, or about 11.5 percent of the gross national product. The Commerce Department expected the growth in health care costs to continue at a 10 to 14 percent annual jump through 1995.

• The Food and Drug Administration approved Zidovudine, commonly called AZT, under a Treatment IND (investigational new drug) program for children under the age of 13 with AIDS or symptoms of advanced HIV infection. Pediatric trials of AZT began in 1986 and involved more than 200 children. Under the new protocol, physicians caring for children three months to 12 years of age who had symptoms of advanced HIV infection were eligible to receive the drug at no cost from Burroughs Wellcome. A recently approved strawberry-flavored syrup form of the drug was to be used.

• T. John Leppi, Ph.D., was named associate dean for admissions and professor of anatomy at Texas College of Osteopathic Medicine.

Obesity and Overweight in America
Obesity Epidemic Increases Dramatically in the U.S.

According to the findings, the obesity epidemic spread rapidly during the 1990s across all states, regions, and demographic groups in the U. S. Obesity (defined as being over 30 percent above ideal body weight) in the population increased from 12 percent in 1991 to 17.9 percent in 1998. The highest increase occurred among the youngest ages (18- to 29-year olds), people with some college education, and people of Hispanic ethnicity. By region, the largest increases were seen in the South with a 67% increase in the number of obese people. Georgia had the largest increase ñ 101%. The findings also show that a major contributor to obesity ñ physical inactivity ñ has not changed substantially between 1991 and 1998.

"Overweight and physical inactivity account for more than 300,000 premature deaths each year in the U.S., second only to tobacco-related deaths. Obesity is an epidemic and should be taken as seriously as any infectious disease epidemic," said Jeffrey P. Koplan, director of the CDC, and one of the authors of the JAMA article. "Obesity and overweight are linked to the nation's number one killer - heart disease ñ as well as diabetes and other chronic conditions."

A national effort is needed to control the epidemic, according to Koplan.

"While obese individuals need to reduce their caloric intake and increase their physical activity, many others must play a role to help these individuals and to prevent a further increase in obesity," Koplan said. "Health care providers must counsel their obese patients; workplaces must offer healthy food choices in their cafeterias and provide opportunities for employees to be physically active on site; schools must offer more physical education that encourages lifelong physical activity; urban policymakers must provide more sidewalks, bike paths, and other alternatives to cars; and parents need to reduce their childrenís TV and computer time and encourage outdoor play. In general restoring physical activity to our daily routines is critical."

According to surveys conducted in 1977-78 and 1994-96, reported daily caloric intakes increased from 2239 Kcal to 2455 Kcal (calories) in men, and from 1534 Kcal to 1646 Kcal in women. Eating more frequently is encouraged by innumerable environmental changes; more food and foods with higher caloric content, the growth of the fast food industry, the increased numbers and marketing of snack foods, increased time for socializing, and a custom of socializing with food and drink.

At the same time, there are fewer opportunities in daily life to burn calories: children watch more television daily; many schools have done away with or cut back on physical education; many neighborhoods lack sidewalks for safe walking; the workplace has become increasingly automated; household chores are assisted by labor-saving machinery; and walking and cycling have been replaced by automobile travel for all but the shortest distances.

According to Koplan, the American lifestyle of convenience and inactivity has had a devastating toll on every segment of society, particularly on children. Research shows that 60% of overweight 5- to 10-year ñold children already have at least one risk factor for heart disease, including hyperlipidemia and elevated blood pressure or insulin levels.

According to CDC research published in the October 13, 1999, issue of JAMA, more than two-thirds of American adults are trying to lose weight or keep from gaining weight but many do not follow guidelines recommending a combination of fewer calories and more physical activity. The 1996 Surgeon Generalís Report on Physical Activity and Health shows that more than 60 percent of adults are not participating in the recommended 30 minutes a day of moderate physical activity most days of the week. The Report stresses that physical activity need not be strenuous to achieve health benefits.

What We Eat in America

More Americans are eating out than ever before, according to results of the 1994-96 Continuing Survey of Food Intakes by Individuals (CSFII) and the Diet and Health Knowledge Survey (DHKS). These surveys, popularly known as What We Eat in America, are conducted by the Agricultural Research Service of the U. S. Department of Agriculture (USDA). The 1994-96 survey collected data on food and nutrient intakes of Americans, behaviors (such as exercise and smoking) that may affect their intakes, and knowledge and attitudes about dietary guidance and health. Interviews with 15,000 individuals of all ages were conducted in 62 geographical areas across the country.

Americans are consuming below the minimum servings recommended for the fruit, dairy and meat groups in the USDAís Food Guide Pyramid. Grain and vegetable consumption is also at the lower ends of the recommended range, and calories from fats and sugars exceed Pyramid recommendations.

The following are selected results from the CSFII:

• Adult females failed to meet the Recommended Dietary Allowances (RDA) for five nutrients ñ calcium, vitamin E, vitamin B-6, magnesium, and zinc. Adult males fell short of the RDA for vitamin E, magnesium, and zinc.

• Fat accounted for 33 percent of calories in the American diet. This represents a continued decrease from 34 percent in 1989-91 and 40 percent in 1977-78. Despite this decrease, in 1994-96, only about one-third of adults met the 30 percent or less of calories from fat recommended by nutrition experts.

• About one in three adults were overweight based on self-reported height and weight compared with about one in five in the late 1970s. Twenty eight percent of adult males and 44 percent of females reported that they rarely or never engage in vigorous exercise.

• Consumption of grain-based products is on the rise. For example, between the late 1970s and 1994-96, Americans increased their consumption of ready-to-eat cereal by 60 percent and their consumption of snacks such as crackers, popcorn, pretzels, and corn chips by 200 percent.

• Consumption of vegetables decreased slightly. And Americans still consume low amounts of dark green and deep yellow vegetables, despite recommendations to do otherwise.

• About 57 percent of Americans ate away from home on any given day. Foods eaten away from home accounted for more than 25 percent of total calorie and fat intakes.

• The percentage of individuals who eat away from home on any given day has increased by a third since the late 1970s. In 1994-96, the most common sources of food away from home for children 5 and under were from someone else, fast food places, and day care.

• For Americans, beverages ñ particularly carbonated soft drinks ñ were the most popular food item consumed outside the home. French fried potatoes and grain mixtures such as pizza, lasagna and ravioli, and Mexican foods are among the foods popular at home or away.

Physical inactivity and unhealthy eating are risk behaviors that have a critical impact on health. Together, they are responsible for at least 300,000 preventable deaths each year. Only tobacco use causes more preventable deaths in the U.S.

Good nutrition lowers a personís risk for many chronic diseases, including coronary heart disease, stroke, some types of cancer, diabetes, and osteoporosis. Americans are slowly changing their eating patterns toward healthier diets. However, a considerable gap remains between recommended dietary patterns and what Americans actually eat. Information from the CDCís Behavioral Risk Factor Surveillance System indicates that only 27% of women and 19% of men eat the recommended five or more servings of fruits and vegetables each day. Although the amounts of total fat, saturated fatty acids, and cholesterol that Americans consume have decreased, they remain above recommended levels for a large proportion of the population.

Despite the proven benefits of being physically active, more than 60% of American adults do not engage in levels of physical activity necessary to provide health benefits. More than one-fourth are not active at all in their leisure time. Activity decreased with age and is less common among women than men and among those with lower incomes and less education.

Regular physical activity improves health in the following ways:

• Reduces the risk of dying prematurely.
• Reduces the risk of dying prematurely from heart disease.
• Reduces the risk of developing diabetes.
• Reduces the risk of developing high blood pressure.
• Helps reduce blood pressure in people who already have high blood pressure.
• Reduces the risk of developing colon cancer.
• Reduces feelings of depression and anxiety.
• Helps control weight.
• Helps build and maintain healthy bones, muscles and joints.
• Helps older adults become stronger and better able to move about without falling.
• Promotes psychological well-being.

Federal Obesity Clinical Guidelines

The clinical practice guidelines are designed to help physicians in their care of overweight and obesity, a growing public health problem that affects 97 million American adults ñ 55 percent of the population.

"Overweight and obesity pose a major public health challenge. The development of these guidelines was a pioneering achievement since they were the first ever developed by the Institute using an evidence-based model and methodology," said NHLBI Director Dr. Claude Lenfant. "This report will be an invaluable clinical tool for any health care professional who works with overweight or obese patients."

The guidelines present a new approach for the assessment of overweight and obesity and establish principles of safe and effective weight loss. According to the guidelines, assessment of overweight involves evaluation of three key measures ñ body mass index (BMI), waist circumference, and a patientís risk factors for diseases and conditions associated with obesity.

The guidelinesí definition of overweight is based on research which relates body mass index to risk of death and illness. The 24-member expert panel that developed the guidelines identified overweight as a BMI of 25 to 29.9 and obesity as a BMI of 30 and above, which is consistent with the definitions used in many other countries, and supports the Dietary Guidelines for Americans issued in 1995. BMI describes body weight relative to height and is strongly correlated with total body fat content in adults. According to the guidelines, a BMI of 30 is about 30 pounds overweight and is equivalent to 221 pounds in a 6í person and to 186 pounds in someone who is 5í6". The BMI numbers apply to both men and women. Some very muscular people may have a high BMI without health risks.

The panel recommends that BMI be determined in all adults. People of normal weight should have their BMI reassessed in two years.

The guidelines recommend weight loss to lower high blood pressure, to lower high total cholesterol and to raise low levels of HDL, and to lower elevated blood glucose in overweight persons with two or more risk factors and in obese persons. Overweight patients without risk factors should prevent further weight gain, advise the guidelines.

In addition to measuring BMI, health care professionals should evaluate a patientís risk factors, such as elevations in blood pressure or blood cholesterol, or family history of obesity-related disease. At a given level of overweight or obesity, patients with additional risk factors are considered to be at higher risk for health problems, requiring more intensive therapy and modification of any risk factors.

Physicians are also advised to determine waist circumference, which is strongly associated with abdominal fat. Excess abdominal fat is an independent predictor of disease risk. A waist circumference of over 40 inches in men and over 35 inches in women signifies increased risk in those who have a BMI of 25 to 34.9.

According to NHANES III, the trend in the prevalence of overweight and obesity is upward. The guidelines note that from 1960 to 1994, the prevalence of obesity in adults (BMI>30) increased from nearly 13 percent to 22.5 percent of the U. S. population, with most of the increase occurring in the 1990s.

The guidelines were reviewed by 115 health experts, and endorsed by the coordinating committees of the National Cholesterol Education Program and the National High Blood Pressure Education Program, the North American Association for the Study of Obesity, the NIDDK Task Force on the Prevention and Treatment of Obesity, and the American Heart Association.

Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults can be found at: www.nhlbi.nih.gov.