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The Unlikely Epedemic-Obesity
By Michelle B. Caughey, M.D. |
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for Dr. Barry Sheppard for Nov/Dec’s President’s Column.
Increasingly,
physicians are treating the consequences and chronic diseases of
obesity. Every year the average BMI (body mass index) of Americans
increases. The number with
morbid obesity, BMI > 35, increases by about 5 percent every five
years. The direct excess cost of diseases associated with obesity in the
year 2000 was $100 billion to $331 billion.1 Humans have
evolved to store excess calories for times of famine, in an environment
of caloric scarcity. Obesity
emerged as a human crisis only in the last century as developed nations
produced more food than they needed and “engineered activity out of
daily life.”2 At the end of
October, I attended the conference “Preventing and Treating Overweight
and Obesity” at the ECRI.3
The medical, public health, and potentially legal approaches needed to
improve the health of Americans are enormous. Physicians must lead the
discussion by providing education to individual patients and the local
community about the consequences of obesity and treatment/lifestyle
changes they must undertake. This starts with pediatricians, family
practitioners, and internists measuring age adjusted BMI on every visit
and referring patients for nutritional education and activity programs
such as KidShape®. Behavioral treatment with maintenance is effective
for at least two years. Specialists must point out to patients that
weight loss can improve co-morbidities such as arthritis and be active
proponents of weight loss. As with smoking cessation, physician
counseling is very effective and should be undertaken at every
opportunity. Unfortunately, most
insurers do not reimburse physicians for treatment of obesity except for
bariatric surgery. Medicare recently revised its regulations and took
out the sentence that declared obesity not a disease (and
therefore not an illness or condition for which Medicare dollars could
be spent.) By taking out the sentence, they did not declare obesity
a disease. This leaves coverage interpretations to regional insurers.
Furthermore, there is no incentive for health care insurers to cover
treatment when the return on that investment is many years in the
future. (At my facility, Kaiser Permanente South San Francisco, patients
stay with the program for an average of about 17 years.) Insurers and
employers who buy health insurance on behalf of their workers should
reimburse treatments that are proved effective, and we must align
incentives between health care providers and insurers to make this
happen. The greatest
opportunity, I believe, involves public policy and public health. Again,
physicians should provide leadership in ways that may or may not be
comfortable for us. What
kind of food do local schools have available? What is the price of each
kind of food? Some schools have experimented with pricing healthy
food below cost and unhealthy high-fat/high-sugar food above cost and
have been able to maintain financial solvency. This strategy does change
kids’ meal choices. Is there a safe place for adults and kids to
walk and play? Some neighborhoods have evaluated lighting, sidewalk
access, hangouts, and the aesthetics of walking areas. Many people is
this country are afraid to leave their homes! We need to remind
patients and town councils/planning commissions that physical exercise
alone, even without weight loss, reduces morbidity and mortality. Hours
of television watched correlates directly with overweight in children
and reducing hours watched actually reduces weight. Other interesting
areas discussed at the conference were food labeling, which can be
deceptive, and the role of the fast food industry. It was noted that
just the threat of litigation has produced dramatic changes in the fast
food industry, including changes in marketing, truth in food labeling,
and increased healthy choices.4
Cultural norms may play a role in certain communities. The prevalence of
obesity is much higher among Hispanic and African American women than
their white counterparts. Treatment of the
chronic diseases associated with obesity will consume all future health
care resources. Doctors will spend much of their time managing and
treating these diseases. We must start now to change our practices,
engage insurers and employers in coverage discussions, and participate
in the public discourse on policy decisions and public health
initiatives. Dr.
Caughey is an internist in South San Francisco. Footnotes: 1
Childhood Obesity – Advancing Effective Prevention and Treatment: An
Overview for Health Professionals prepared for the National Institute
for Health Care management Foundation Forum, April 9, 2003. 2
Personal communication, William Caplan, MD 3
see www.ecri.org for more information 4.
Consumber Policy Review, vol 13, No. 5; Sep/Oct 2003, p. 154-158.
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