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Registered dietitian Almost all average size hospitals had an outpatient nutrition department, usually staffed by one full time registered dietitian mostly devoted to the outpatient nutritional counseling of patients with chronic illness, primarily diabetes or cardiovascular disease. Several dietitians noted that these outpatient departments were not run as profit centers. Medicare reimbursement averaged $60 per hour, with the remaining $15 the patient’s responsibility. Commercial insurance reimbursement averaged $100 per hour, less copays or coinsurance. Dietitians’ base salaries averaged between $50,000 and $70,000. Due to cancellations, paperwork, and correspondence, dietitians rarely achieved a 75% chargeability ratio.
Registered dietitians also practiced individually. Their practices were limited in numbers and clients were mostly patients with eating disorders (e.g., parents willing to pay out of pocket for multiple visits to address their child’s eating disorder).
Lindora, Inc. was a privately held medical weight loss company with an estimated $40 million in revenues. Lindora operated 35 weight loss clinics in southern California staffed by physicians, nurses, and nurse practitioners. Clients begin with a brief medical history, comprehensive lab screening, and blood pressure reading. A customized weight loss program was then developed for each participant. Clients followed a low-carbohydrate, low-fat diet for up to eight weeks and visited the clinic daily, Monday through Friday, to check their progress. A two-week adjustment period was followed by an 18-month program to develop eating practices to stay slim. [64]
Lindora averaged 3,500 patient visits per week at a cost to participant of $25–$95 for the five-day-a-week program. Eighty percent of the clients were women. Discounts (20%) were available through major area insurers. [65]
The prescription drug treatments were appetite suppressants or digestive inhibitors.
Orlistat (Xenical), had worldwide sales of approximately $345 million in 2009. [66] (Over-the-counter it was called Alli.) It worked in the digestive system to block approximately one-third of the fat in food. When taken with meals, Xenical attached to lipases (enzymes that break down fat in the digestive system) and blocked them from acting. [67] In a clinical study, 33% of dieting patients using Orlistat lost at least 10% of their body weight in 12 months versus 25% of dieting patients using a placebo. [68] Adverse effects included cramping, oily stools, and diarrhea. [69]
Sibutramine (Meridia), also approved for weight loss, had U.S. sales of approximately $37 million in 2008. [70] It worked by acting on the appetite control centers of the brain. [71] Adverse effects, including increases in blood pressure and/or heart rate, caused public petitions to recall it. [72] One review claimed it led to a loss of 5–22 lbs. in one year. [73]
Other medications, including antidepressants, also promoted moderate weight loss when prescribed along with diet recommendations. [74]
Various types of bariatric surgery were performed: 95% of operations were or included procedures that created small upper-gastric pouches that held 10 teaspoons of volume. [75] Most operations used laparoscopic, minimally invasive techniques, which were technologically more difficult to perform than open procedures, but associated with a reduced length of hospitalization, early return to full activity, and fewer infections. [76] Most were performed in the hospital but lap banding of the stomach to decrease its size was performed outpatient.
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