Weight-Loss Bonus: Costs for Obesity-Related Meds Drop

Marlene Busko
November 18, 2013

Obese patients who successfully shed pounds by following a medical weight-loss program may reap the reward of lower medication costs for common comorbidities, new research suggests. The single-center, retrospective study was presented in an oral presentation at Obesity 2013: The Obesity Society Annual Scientific Meeting.

After following the program for an average of 22 weeks, patients who typically had a starting weight of about 250 pounds lost about 44 pounds. They also spent, on average, $70 less a month for medications for 4 common comorbidities: diabetes, hyperlipidemia, hypertension, and gastroesophageal reflux disease (GERD).

This shows that “weight loss in a medically supervised setting has the potential to significantly decrease the medication expenses associated with obesity comorbidities, most of all diabetes,” Clay P. Wiske, a medical student currently at Harvard Business School, in Boston, Massachusetts, told the audience.

“There hasn’t been very much published on the cost of medical weight-management programs…partly because [the programs are] not very homogeneous,” senior author Vincent Pera, MD, from Brown University in Providence, Rhode Island, told Medscape Medical News. “My guess is that no matter how the weight loss is achieved [including by bariatric surgery], you would see these kinds of benefits in medication reduction.”

The research was about “medication cost savings” as opposed to “cost-effectiveness,” he acknowledged, and the calculations did not include the cost of participating in the 5-month program, which was about $2000 per patient. About 2 or 3 insurance companies cover the entire cost, he noted.

The latest obesity guidelines, issued by the Obesity Society last week, stress medically supervised programs as a central tenet for successful weight loss, emphasizing that the evidence shows patients need help to shed the pounds. However, this type of program is very poorly reimbursed at present, at least by the Centers for Medicaid & Medicare Services (CMS) — at a rate of around $20 a visit. Coverage of such programs by private insurers in the United States is patchy; it is hoped the new recommendations will encourage more of them to reimburse such schemes.
Can “Low-Risk” Strategies Cut Costs?

Mr. Wiske told the audience that because many recent studies have looked at potential cost savings following bariatric surgery, “we were curious to see whether we would see savings with interventions that were less risky, such as medically supervised weight loss.”

On average, an obese adult living in the United States pays an estimated $2460 more in annual healthcare costs than his or her thinner counterparts, he said. The researchers hypothesized that the medically supervised weight-loss program offered at the Merriam Hospital in Providence, Rhode Island would lead to a decrease in medication costs.

They retrospectively analyzed data from 589 obese patients who participated in this program between 2009 and 2012 and, importantly, completed at least 16 weeks of treatment.

The patients had a mean age of 49 years and 70% were women. When they entered the program, they were taking an average of 4.6 medications, of which 1.6 were for the studied 4 comorbidities.

At baseline, half of the patients had hypertension, 47% had hyperlipidemia, 44% had GERD, and 20% had diabetes. Some patients did not have any of these comorbidities.

When they enrolled, the patients received counseling about 3 types of 1200-calorie-a day meals:

  • Complete meal replacement.
  • 800 calories from meal replacements plus one “regular” meal.
  • No meal replacements, but instead, a tailored, healthy diet.

The meal replacements were Optifast (Nestle) products, most commonly shakes, said Mr. Wiske. About 20% of patients did not take meal replacements, and the rest were split between the 2 types of meal-replacement plans.
All patients were offered weekly physician visits, weekly weigh-ins, counseling sessions with a dietician and an exercise physiologist, plus group education and discussion sessions.

On average, the patients lost about 17.5% of their initial body weight. The weight loss and medication reduction were similar for the patients in the 3 groups.

The average overall monthly wholesale cost of the studied medications fell from $150 to $77, with the largest reduction coming from the drop in cost of diabetes medications.

A multivariate linear model adjusted for physician visits demonstrated that total weight loss, number of nutrition and exercise counseling sessions attended, previous diagnosis of hypertension and hyperlipidemia, as well as number of initial medications were all positively correlated (P < .05) with percent decrease in monthly wholesale medication costs.
Longer Study Needed

“Future research should focus on the longevity of this effect and should include all healthcare costs,” Mr. Wiske concluded.

In response to a question asking how they were able to get people who weigh 250 pounds to stick to a 1200-calorie diet, he explained that the patients were all highly motivated, and some had entered the program because it was a prerequisite for surgery.

Asked to comment, session moderator Ken Fujioka, MD, from Scripps Clinic, San Diego, California, observed that although this was a retrospective study, “still, it had some interesting points — it showed that if you get weight loss, you can save some money…you save medication cost and you get somebody healthy.” However, the study was short and did not examine all costs.

And recent studies looking at bariatric surgery have been unable to prove long-term overall healthcare cost savings, he noted.

Obesity 2013: The Obesity Society Annual Scientific Meeting. Oral presentation, presented November 14, 2013.


Current BMI Cutoffs May Miss Metabolic Disease Risk

Marlene Busko
November 14, 2013

ATLANTA — About a third of men and almost half of women classed as nonobese based on body mass index (BMI) alone had a high percentage of body fat; moreover, they were 10 times more likely to have metabolic syndrome than their peers, researchers report. In addition, gauging risk based on sedentary behavior alone may be misleading, they discovered.

The new findings, based on data from the 2003–2006 National Health and Nutrition Examination Survey (NHANES), were presented in a poster here at Obesity 2013: The Obesity Society Annual Scientific Meeting.

“BMI is potentially missing a lot of people who are at risk,” since they have “normal-weight obesity,” lead author Mark D. Peterson, PhD, from the University of Michigan, Ann Arbor, told Medscape Medical News.

Dr. Peterson does not believe that the BMI threshold to detect obesity will ever be lowered from 30 kg/m2. But he hopes the study results will draw attention to a segment of the population that might be missed when screening for disease risk if waist circumference or percentage of body fat is not considered.
The study also suggests that overall level of physical activity, not time spent being sedentary, is the better predictor of metabolic syndrome, say he and his colleagues.
Does BMI Accurately Predict Metabolic Syndrome?

The best way to screen for obesity, risk for cardiovascular disease, and diabetes remains controversial, and misclassification is common, the researchers explain. While BMI is used as a surrogate marker for adiposity to screen people, it does not distinguish between fat and muscle, Dr. Peterson pointed out.

In addition, time spent being sedentary is believed to contribute to risk for preventable disease and mortality, which is a growing topic of interest, he noted.

To investigate these 2 aspects of screening, the researchers analyzed data from 5576 participants of the 2003–2006 NHANES who were 20 to 85 years old and for whom data were available detailing blood pressure, measures of BMI, waist circumference, body fat, and activity levels.

Nonfasting serum measures of HDL cholesterol and high-sensitivity C-reactive-protein (hs-CRP) concentrations were also taken, as were fasting measures for triglycerides, plasma glucose, and insulin. Metabolic syndrome was defined as the presence of any 3 or more of the following:
 Abdominal obesity (> 102 cm for men; > 88 cm for women).
 Elevated triglycerides (> 1.7 mmol/L).
 Reduced HDL cholesterol (< 1.0 mmol/L in men; < 1.3 mmol/L in women).
 Hypertension (> 130 mm Hg systolic and/or > 85 mm Hg diastolic).
 Elevated fasting glucose (> 100 mg/dL).

Total body fat percentage was based on dual-energy X-ray absorptiometry readings, and obesity was defined as body fat of 25% or more for men and 35% or more for women.

Activity levels were based on 4 days of measurements from an accelerometer, which is a small device worn attached to the hip that is similar to a pedometer but that also counts movement intensity, Dr. Peterson explained.

A Very Obese Nation

BMI readings of 30 kg/m2 and above had excellent specificity in both men and women but very poor sensitivity; based on this cutoff, 30.6% of men and 37.5% of women were defined as being obese. Using body-fat percentage instead, the researchers found that 71.1% of men and 79.6% in women in this representative national population sample would be classed as obese (P < 0.001).

And 32.8% of the men and 45.7% of the women with a normal weight based on BMI measurements (18.5–24.9 kg/m2) were identified as obese according to body-fat percentage.

While less than a fifth of the men (17.5%) and women (16.7%) surveyed had metabolic syndrome, those who were classed as obese according to percentage of body fat had about a 10-fold increased likelihood of metabolic syndrome (odds ratio [OR], 9.64 for men; OR, 10.58 for women).

Age, education, percentage of body fat and being in the highest quartile for sedentary behavior (> 9.5 hours for men and > 9.25 hours for women) were all significantly associated with higher odds of having metabolic syndrome. Lower annual income was an independent predictor of metabolic syndrome for women only.

However, after adjustment for overall total activity, sedentary behavior was no longer associated with an increased risk for metabolic syndrome.

Use a BMI of 27.5 to Define Obesity?

“Dr. Peterson has some evidence that maybe we should be using a [BMI] cut point of 27 to 28 — and anything above that would be obese — which correlates better with body-fat percentage than the cut point of 30,” William D, Johnson, PhD, from Pennington Biomedical Research Center, Baton Rouge, Louisiana, pointed out when asked to comment. He himself has a BMI of 30 kg/m2, he noted, which brings this study close to home.

“If people would accept that cut point, that would redefine BMI,” he added, but like Dr. Peterson, he does not think that is likely, although some underdeveloped countries where people are very lean do use a lower BMI to define obesity, he noted.

This study was supported in part by the National Institutes of Health National Center for Medical Rehabilitation Research, National Institute on Neurological Disorders and Stroke, and National Institute on Aging.


November Is National Diabetes Awareness Month

Learn More About Diabetes and How Medical and Surgical Clinic of Irving Is Actively Combating the Disease

Diabetes is a disease that affects the body’s ability to produce or recognize insulin, which in turn causes issues with proper management of the blood’s glucose (or sugar) levels. Insulin is a hormone that allows for the body’s cells to absorb glucose and use it for energy.

When the body is unable to use glucose for energy due to a lack of insulin or its inability to recognize insulin, the body’s cells become starved for energy. Left untreated, this can lead to serious health issues including heart attack, stroke, blindness or, in very severe cases, mild or severe nerve damage that may eventually require amputation. Nearly 26 million adults and children in the U.S. have the disease in one of its variety of forms: gestational diabetes, type 1 diabetes and type 2 diabetes.

Understanding the Different Types of Diabetes

Gestational diabetes is developed by some women during pregnancy, often around the 24th week. Those who are diagnosed with gestational diabetes did not necessarily have diabetes prior to their pregnancy and will not necessarily have diabetes after giving birth. It is important for them to follow their doctor’s advice on glucose levels throughout the pregnancy to promote the best health for themselves and their babies. Unlike with other forms of diabetes, it is possible that gestational diabetes will only last the duration of the pregnancy and will not be a lifelong illness.

Type 1 diabetes is a disease caused by the pancreas’ total inability to produce insulin. This type of the disease is most common in children but also affects adults. Only 5 percent of people in the U.S. with diabetes have type 1 diabetes. Type 1 diabetes can be easily managed with doctor recommended insulin therapy and a variety of additional medical treatments.

Type 2 diabetes is the most serious and most common form of the disease.  Those who suffer from Type 2 diabetes produce too much insulin due to what’s called “insulin resistance.” This means that the body’s cells are unable to properly use that insulin to absorb glucose for energy. People with Type 2 diabetes require a doctor’s uniquely tailored treatment plans and regular blood sugar and cholesterol level monitoring to successfully combat the disease as effectively as possible.

Steps to Take to Start Managing Symptoms Today

Although there is no cure for diabetes types 1 and 2, there are simple life changes that people can make to help mitigate their symptoms. Here are a few ways to combat diabetes that, partnered with a medical treatment plan, can help patients to take control of their symptoms so that they can get back to enjoying their lives.

  • Stay at a healthy weight.  Avoiding processed foods and simple sugars while choosing “low glycemic index” fruits and vegetables and lean proteins can help with this.
  • Get moving with some light or vigorous cardio workouts three to five times weekly.
  • Do something twice a week to increase muscle strength.
  • Wash hands frequently to avoid illness. Those with diabetes are affected more seriously by viruses such as the flu or a cold, so it’s important to keep as healthy as possible.
  • Stop or don’t start smoking or using tobacco.

How Medical and Surgical Clinic of Irving Helps Patients Fight Diabetes

Although taking the steps above will help to minimize the negative symptoms of diabetes, it’s still necessary for those with the disease to regularly see a doctor for checkups to ensure that blood sugar and cholesterol levels are remaining normal and that serious symptoms of the disease do not go untreated.

The expert family medicine, internal medicine and endocrinology physicians at Medical and Surgical Clinic of Irving are available to schedule appointments for diabetes assessments and recommend ongoing treatment plans. Visit our specialties page to learn more about the experienced practitioners available to assist patients with diabetes by monitoring their illness and proactively treating its symptoms. Read through each physician’s biography to discover more about their experience treating diabetes.






Phone App Aids Weight Loss

Smartphone apps could help people to lose weight by encouraging them to notice and record the amount of food they consume as they eat, according to a new feasibility study presented here at the ECO2013, the 20th European Congress on Obesity.
The research by Eric Robinson, PhD, from the University of Liverpool, United Kingdom, and colleagues builds on their previous work on attentive eating, which concluded that distractions, such as radio, television, and computers, increased food intake by up to 50%, both during a meal and later in the day.
On the basis that paying attention to what is eaten and remembering it clearly help reduce energy intake, Dr. Robinson and colleagues designed a smartphone application that would help promote food memory in overweight or obese people.
The 1.5-kg average weight loss observed in their 4-week study “is similar to a recent more intensive 2-month trial that investigated the impact of dietary/exercise advice and habit formation,” said Dr. Robinson. This suggests that “raising awareness of eating and weight loss achieved” could be a fruitful approach, he observed.
Approached by Medscape Medical News for comment, Allan Geliebter, PhD, from the New York Obesity Research Center at Columbia University, New York City, said that heightening awareness of food intake is an important factor in combating excessive food consumption. And the use of a phone app is particularly exciting, because of its practicality and the intrinsic attractiveness of such technology, he noted.
Promising Findings, but Longer-Term Trials Needed
The app consists of 3 main parts. Before eating or drinking, users photograph the food/drink about to be consumed under a “snap” function; they are reminded by text to complete a “most-recent” photograph when they have finished.
Second, users focus on the on-screen “most-recent” image after the meal and answer questions on quantity eaten and feelings of satiety.
The final part opens a chronological slide show of the consumption episodes recorded during that day. A short text message instructs users to remember what they have eaten and reminds them to eat attentively and to snap their next meal.
Twelve overweight (n = 5) and obese (n = 7) participants took part in the trial. Mean body mass index (BMI) was 32.1, mean weight was 96.3 kg, and mean age was 42 years. They were compensated with £30 ($45) for their time.
Mean weight loss was -1.5 kg over the 4 weeks. Half the participants (6/12) lost 1 kg or more, 4 lost between 0 and 1 kg, and the remaining 2 gained between 0.1 and 0.4 kg. The individuals accessed the application on average 5.7 times a day, and the mean number of eating and drinking episodes recorded daily was 2.7.
“Our study introduces a new attentive eating approach aimed at reducing dietary intake and promoting weight loss, supported by theoretical models of the role of memory on energy intake regulation,” said Dr. Robinson.
“Results suggest that a simple smartphone…intervention based on these principles is feasible and could promote healthier dietary practices. Maybe you can’t imagine people using this app for the rest of their lives, but it might help them to develop better eating habits.
“Given that our trial was a very brief intervention with little contact time and no nutritional advice or support, this is a promising finding,” he added.
However, he stressed that a larger, randomized controlled trial “testing proof of principle for an attentive eating intervention on weight loss is now warranted,” because long-term maintenance of changes to the diet and weight loss are hard to achieve.
Dr. Geliebter told Medscape Medical News: “This has huge potential for taking action on obesity on a population basis, particularly since it is an app — which makes it intrinsically attractive.” However, one of the important factors determining whether it will ultimately prove successful when it is rolled out will be “whether [or not] the app is free,” he observed.

Article written by Rachel Pugh
Research was funded by the UK National Institute for Health Research National School for Primary Care Research. Neither Dr. Robinson nor Dr. Geliebter has reported relevant financial relationships


September Is National Childhood Obesity Awareness Month

Follow These Tips to Help Keep Your Child at a Healthy Weight

Childhood obesity is a serious problem in the United States. One in three children is overweight, putting the child at risk for health problems that until recent history were primarily associated with adults. Overweight children can develop heart disease, high blood pressure, type 2 diabetes and asthma. They’re also at risk for psychological issues such as low self-esteem, trouble with sleeping and depression.

Armed with the right information, parents can successfully help their children get down to and maintain a healthy weight. Although the issue is a serious one, the solution doesn’t have to be. In fact, it can be downright fun. The Medical and Surgical Clinic of Irving recommends a light approach to family health based on the reality that active children are happy and healthy.

Here are a few of the many enjoyable steps (or skips, if preferred) that parents can take toward improving their children’s health:

  • Play ball. Sports like soccer, basketball, hockey and tennis offer a tremendous regular cardio workout. Children also develop important social skills like how to play well with others and work as a team.
  • Dance like a fool. Ballet, tap and hip-hop classes give children the opportunity to express themselves while working up enough of a sweat to burn some major calories. As an added bonus, parents are sure to get memorable video footage of the requisite seasonal class recital.
  • Go for a ride. Parents could invest in bicycles for themselves and their children. Regular family bike rides are relaxing and hugely beneficial to long-term health. If there is a park nearby, taking a trip to the jungle gym is a great way to up the fitness ante with some child-style strength training.
  • Walk it out. For those who would rather steer clear of bicycles, a good old-fashioned daily stroll can do wonders for maintaining a healthy weight. A great time to go for a walk is after dinner. The activity will help with digestion, will give parents added quality time with their kids and supply an added boost of energy to what is sometimes a sluggish part of the day.
  • Turn off the tube. It is important to set rules for the amount of time children can sit in front of the television or computer, and to stick to them. Without electronic distractions, children will need to get creative to entertain themselves – which will likely mean doing something active like rollerblading or jumping rope.
  • Chalk it up to a good time. With a little chalk and imagination, a hopscotch course can be formed. This competitive hopping game is great for strengthening bones and makes for a good cardio workout. Kids love to draw on the sidewalk – and, lucky for parents, the course will wash away after the next rain.
  • Get cookin’, good lookin’. Good nutrition is essential to maintaining a healthy weight, and children who are involved in food preparation tend to be more likely to eat healthy meals. Start simple with ants on a log (celery topped with peanut butter and raisins), or make a low-calorie pizza by topping a wheat crust with tomato sauce, low-fat mozzarella and veggies.
  • Play hide and seek – and win. The pickiest of eaters won’t be placated by putting on a chef’s hat, so parents have to get creative. Finely processed vegetables are invisible to the eye and taste buds when baked into meatloaf or mixed in a thick tomato sauce. Missy Chase Lapine’s The Sneaky Chef has several easy-to-make recipes that are sure to have kids asking for seconds and parents piling more hidden veggies onto their plates.

If parents are concerned that their child might be obese, it is important that they take him or her to visit a doctor for a professional evaluation. Children develop at different rates, and some have naturally smaller or larger builds than others. A medical professional will be able to assess whether a child is a healthy weight for his or her age, height and frame while also offering further advice on the best steps to reach a healthy weight. The professionals at the Medical and Surgical Clinic of Irving are here as a resource for parents concerned about their children’s weight and any other medical matter.






Lab Study Links Sleep Deprivation to Weight Gain

Restricting sleep to 4 hours a night for 5 consecutive nights led to more weight gain for sleep-restricted participants than for control participants, according to results from a large, diverse, in-laboratory assessing sleep’s effect on weight, calorie intake, and meal timing. The study was published in the July issue of Sleep.

Doctoral candidate Andrea M. Spaeth, MA, from the Department of Psychology, School of Arts and Sciences, University of Pennsylvania, Philadelphia, and colleagues conducted a study involving 225 healthy adults aged 22 to 50 years at the Sleep and Chronobiology Laboratory at the Hospital of the University of Pennsylvania. Study participants were all nonsmokers whose body mass index (BMI) ranged from 19 to 30 kg/m2 and who did not experience any irregular sleep/wake routines during the 60 days before the study.

Researchers monitored the participants for a week at home before the laboratory phase, during which they studied the participants for 12, 14, or 18 consecutive days. They randomly assigned participants to either sleep restriction (SR; n = 198) or control (n = 27). SR participants were 45% women and 59% black, with a mean age of 31.3 years and a mean BMI of 24.8 kg/m2. Control participants were 44% women and 63% black, with mean age of 31.9 years and a mean BMI of 25 kg/m2.

SR participants had 2 initial nights of 10 to 12 hours in bed, followed by 5 consecutive nights of 4 hours in bed (from 4 am to 8 am). Control participants had 10 hours in bed (from 10 pm to 8 am). During the laboratory phase, participants could not leave the laboratory and could not exercise but were permitted to watch television, read, play video or board games, and do other sedentary activities while not sleeping or during testing while sitting at a computer.

The researchers monitored calorie intake in a subset of participants (31 SR and 6 control participants). They also measured and weighed all food provided during protocol-specified meal times. However, participants were allowed to eat whenever they wanted if it did not interfere with testing. Monitors recorded all food and drink consumed and left over. They measured body weights 6 to 7 days before the laboratory phase, on admittance, and on discharge.

SR participants gained significantly more weight (0.97 ± 1.43 kg) than control participants (0.11 ± 1.85 kg), possibly because of late-night eating and eating meals with higher fat content, the researchers write. SR participants whose caloric intake was monitored gained 0.52 ± 1.60 kg compared with control participants, who lost 0.53 ± 1.16 kg.

In addition, among SR participants, men gained more than women (P = .004) and blacks gained more than whites (P = .003).

“Although previous epidemiological studies have suggested an association between short sleep duration and weight gain/obesity, we were surprised to observe significant weight gain during an in-laboratory study,” Spaeth said in a news release.

“African Americans, who are at greater risk for obesity and more likely to be habitual short sleepers, may be more susceptible to weight gain in response to sleep restriction. Future studies should focus on identifying the behavioral and physiological mechanisms underlying this increased vulnerability.”

One coauthor has received funding for serving as a consultant, as a National Institutes of Health section member, and for lecturing and is an associate editor of Sleep. One coauthor is compensated by the Associated Professional Sleep Societies for serving as editor-in-chief of Sleep. Spaeth has disclosed no relevant financial relationships. Sleep. 2013;36:981-990

Article by Larry Hand


Eating Insects Could Help Fight Obesity, U.N. Says

The authors of a U.N. report published on Monday said the health benefits of consuming nutritious insects could help fight obesity.

More than 1,900 species of insects are eaten around the world, mainly in Africa and Asia, but people in the West generally turn their noses up at the likes of grasshoppers, termites and other crunchy fare.

The authors of the study by the Forestry Department, part of the U.N. Food and Agriculture Organization (FAO), said many insects contain the same amount of protein and minerals as meat, and more healthy fats.

“In the West we have a cultural bias and think that because insects come from developing countries, they cannot be good,” said Dr. Arnold van Huis from Wageningen University in the Netherlands, one of the authors of the report, which was released at a news conference at the UN’s Rome headquarters.

Eva Muller of the FAO said restaurants in Europe were starting to offer insect-based dishes, presenting them to diners as exotic delicacies.

Danish restaurant Noma, for example, crowned the world’s best for three years running in one poll, is renowned for ingredients including ants and fermented grasshoppers.

As well as helping in the costly battle against obesity, which the World Health Organization estimates has nearly doubled since 1980 and affects around 500 million people, the report said insect farming was likely to be less land-dependent than traditional livestock and produce fewer greenhouse gases.

It would also provide business and export opportunities for poor people in developing countries, especially women, who are often responsible for collecting insects in rural communities.

Van Huis said barriers to enjoying dishes such as bee larvae yogurt were psychological – in a blind test carried out by his team, nine out of 10 people preferred meatballs made from roughly half meat and half mealworms to those made from meat.

By Catherine Hornby


Five Weight-loss Roadblocks

Think you’re doing everything right with your diet, but still not dropping any pounds? One of the dieting obstacles below might be to blame. Avoid these five weight-loss roadblocks on the path to a healthier you:

Stress: When you’re stressed out, your body releases a hormone that causes you to crave fatty, sugary foods. Avoid stress and you might be able to resist dessert.

Unhealthy “healthy” foods: Labels such as “all natural” and “fat-free” can be misleading and may not tell the whole story. Make sure you check the nutritional facts to see exactly what you’re eating.

Not enough sleep: Too little time spent asleep may keep your body from producing hormones that regulate your appetite, causing you to overeat. To keep your diet on track, make sure you’re getting at least six to eight hours of sleep each night.

Missing a workout: We all know missing a workout means burning fewer calories, but new research shows that people who skip the gym are more likely to give in to temptation when it comes to their diet.

Eating out: Most restaurants are concerned with how your food tastes, not your waistline. Because restaurant foods tend to have more calories, sodium and fat, consider cooking more meals at home when trying to shed a few pounds.