Putting a Price on Fat

Cost of Obesity-Related Illness Could Overwhelm Health Care Delivery

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Legislative Affairs Feature -- April 2004

By  Ken Ortolon
Senior Editor

America's waistlines are expanding. Federal health officials now estimate that more than 60 percent of American adults are either overweight or obese. And the number of overweight children in America has tripled in the past 20 years.

As the needles on our scales inch higher, so too does the price we all pay for our poor diets and sedentary lifestyles. According to a new study published in the February issue of Obesity Research , American taxpayers are now footing the bill to the tune of $39 billion annually -- roughly $175 per man, woman, and child in the United States -- for medical care of obesity-related diseases such as type 2 diabetes and cardiovascular disease.

These statistics have not been lost on state officials in Texas, where obesity rates exceed the national average. Texas Commissioner of Health Eduardo Sanchez, MD, says the number of obese adults in Texas is nearing 25 percent, while research by The University of Texas School of Public Health in Houston shows that almost 40 percent of fourth graders in the state are either overweight or at risk of being so.

The health consequences likely to result from our collective weight problems are staggering in terms of increased incidence of diabetes, heart disease, certain types of cancer, gallbladder disease, and other chronic illnesses associated with obesity. But state officials say the consequences to our health care delivery system also will be enormous if we do not reverse obesity trends now.

"We have an epidemic of obesity in the state of Texas, just like any other state," Commissioner Sanchez said. "It's a problem that cannot be ignored."

And it is not being ignored. From the governor, to the state agencies responsible for public health and agriculture, and on to the Texas Legislature, a tremendous amount of attention is being paid to obesity this year. State policymakers hope to make a difference in the health status of Texas children and adults and save public and private payers of health care from an enormous bill in the future.

Doing the Math

State health officials estimate that Texans now spend at least $10 billion annually in both direct and indirect costs to treat illnesses related to obesity and overweight. That figure includes both public and private payers.

Texas Agriculture Commissioner Susan Combs says that figure is likely to grow exponentially over the next few decades if obesity is not addressed. She says the incidence of obesity in children has grown from about 5 percent 30 years ago to close to 25 percent today. Extrapolating that out means we are likely to have four to five times more obese adults in the future.

"You could argue, and I do argue, that we're looking at potentially $40 billion per year in Texas if we leave this unchecked," she said.

Commissioner Sanchez agrees. "When you look at what constitutes the cause of death, 70 percent of deaths occur due to chronic disease," he said. "Many of those chronic diseases could be prevented, delayed, or better controlled if obesity wasn't one of the cofactors playing a role in the management of that condition."

He says the American Diabetes Association estimates the annual cost of health care for treating a person with diabetes is roughly $13,000. That compares to between $2,000 and $2,500 spent on nondiabetic adults.

"Can we accept the fact that one out of three children born today are likely to develop diabetes in their lifetime? Can we sustain our medical care delivery system if we go down that path?"

Taking on the Fat

The answer from state policymakers is a resounding no, and they have begun to tackle the issue head-on. With encouragement of the Texas Medical Association and a coalition of other public health advocates, the legislature in 2001 passed Senate Bill 19, sponsored by Sen. Jane Nelson (R-Flower Mound), to require more physical activity for elementary students and comprehensive fitness and nutrition programs in the schools.

Initial implementation of SB 19 was slow among elementary campuses across the state. Some school districts were confused about whether SB 19 required additional physical education classes that might force them to hire more physical education teachers, or whether they simply needed to provide more physical activity time for the students. And some classroom teachers grumbled about having to take on the responsibility for supervising physical activity. (See "Fat Kids On the Block," April 2003 Texas Medicine.)

In 2003, state Sen. Eddie Lucio (D-Brownsville) and Rep. Jaime Capelo (D-Corpus Christi) tried to take it a step further. They authored SB 474, which would have created a Nutrition and Health Advisory Council charged with upgrading nutritional standards for meals and food served in Texas public schools, as well as standards regarding physical education. The bill also would have placed restrictions on the provision of food by parties other than the school district and prohibited undue contact between school employees and food vendors.

That bill met considerable opposition from soda and candy manufacturers, as well as local school boards, which rely heavily on revenue generated through vending machine contracts and "a la carte" contracts with fast food chains such as Pizza Hut, McDonald's, and Burger King.

The final version simply authorized a joint legislative committee to conduct an interim study on nutrition and health in the public schools. Lt. Gov. David Dewhurst did not make Senate appointments to the panel until late February, so work on the study was just getting under way in March. The panel is to submit its report to the legislature by Oct. 1.

Meanwhile, the House Public Health Committee, chaired by Representative Capelo, is conducting an interim study of diabetes and the role of obesity in that disease. And, the House Select Committee on Health Care Expenditures, which is examining ways to maintain access to care while reining in costs, has at least recognized that obesity is a growing factor in the cost of care.

Commissioners Combs and Sanchez also have taken aggressive action to begin addressing childhood and adult obesity problems. Last summer, control of the state's school lunch and breakfast program was transferred from the Texas Education Agency to the Texas Department of Agriculture (TDA). Almost immediately, Commissioner Combs issued new rules that placed strict limits on vending machines and so-called foods of "minimal nutritional value" in the state's public elementary schools. (See "Junk Food Junked," October 2003 Texas Medicine , pages 31-34.)

While school food service personnel, dietitians, and parents supported the move, it wasn't as well received among school boards and administrators.

"It struck me from every conceivable aspect that it was something we had to do," she said. "When you've got a kid who is really unhealthily overweight and we don't do something about it, and we have our school environment where they're not always doing everything they need to do, it's just awful. The school folks are put in this terrible, terrible spot of, in some cases, knowingly engaging in bad nutritional policy in return for dollars."

Pushing the Envelope

Still, Commissioner Combs says she intends to "push the envelope" even more aggressively on school nutrition. On March 1, TDA issued a new policy that outlaws all candy and foods of minimal nutritional value on elementary campuses and limits their availability on middle school and high school campuses. The proposed rules also limit the fat content of foods available in vending machines, served a la carte by fast food chains, and served in elementary school cafeterias. They also set standards for portion sizes.

Her ultimate goal is to take candy out of the schools completely.

She also had floated a trial balloon on a proposal to reward schools financially for achieving certain nutrition and fitness levels among students. While the details of that proposal were still being developed, Commissioner Combs says she believes the proposal could be considered in a special session Gov. Rick Perry is expected to call this spring on school finance.

Meanwhile, the Texas Department of Health (TDH) also is tackling obesity. In February 2003, the department issued a strategic plan for obesity prevention that established goals to increase awareness of obesity as a public health issue. The plan also strives to mobilize families, schools, and communities to create opportunities to choose lifestyles that promote healthy weight, promote policies and environmental changes that support healthy eating habits and physical activity, and monitor obesity rates and related behaviors and health conditions.

Commissioner Sanchez says raising awareness is key. "I think it's important, first of all, that people at least appreciate that there is an issue to be considered," he said. "We're at the point now where we're willing to at least acknowledge that there is a problem, which is the first step toward problem resolution."

TDH recently received nearly $450,000 from the U.S. Centers for Disease Control and Prevention to begin putting the strategic plan into action. Meanwhile, Commissioner Sanchez says the state may also need to consider stepping up its commitment to research on obesity prevention, including the possibility of employer-supported wellness interventions to combat adult obesity.

"Some data out there suggest that some large corporations have invested dollars in wellness and have seen a return on investment that has made that reallocation of health benefits dollars something they've found beneficial to the bottom line," he said.

The state has several hundred thousand employees -- plus retirees and dependents -- receiving health coverage through the Employees Retirement System of Texas. Dr. Sanchez says that may be a good place to start with some limited pilot programs that could measure the effectiveness of employee wellness programs.

Ken Ortolon can be reached at (800) 880-1300, ext. 1392, or (512) 370-1392; or by email at Ken Ortolon.

SIDEBAR

The Fitness Round-Up

Gov. Rick Perry has made fitness a major priority. First, he reestablished the Governor's Council on Physical Fitness, which had been dormant for a number of years. And, in partnership with a wide range of groups, including the Texas Medical Association, public health advocates, and even the fast food industry, he is launching the Texas Round-Up to encourage Texans to incorporate physical activity into their daily lives and to commit to a more active lifestyle.

The round-up encourages Texans to sign up for a six- to 10-week activity program. It also will feature a health and fitness expo in Austin on April 16 and 17. The event includes a "Texas-sized" 10-kilometer run/walk that Governor Perry hopes will attract 55,000 participants.

Finally, a Governor's Challenge will encourage communities to participate. Cities or regions with the highest participation rate per capita in the activity program and local 10-kilometer events will be awarded the Governor's Cup and named the "Fittest in Texas."

Speaking to physicians at the TMA Winter Conference in February, the governor called obesity in Texas an "epidemic of extraordinary proportions that's totally preventable. If we get more Texans in shape, fewer of them are going to end up in the emergency rooms across the state with conditions like diabetes and heart disease."

SIDEBAR

UT Southwestern Study May Solve Obesity Problem

Increasing leptin in laboratory animals transforms fat-storing cells into unique fat-burning cells, researchers at The University of Texas Southwestern Medical Center at Dallas have found. They speculate their findings could provide "a quick and safe solution" to human obesity.

Researchers attribute the change in the cell's structure and function in rats to increased action of mitochondria, the principal energy source of the cell. The increase in mitochondria, which also led to substantial weight loss in the rats, was found two weeks after researchers injected the leptin gene.

"The structure of the cells changed from the normal appearance of a fat cell to a very novel cell that's really never been seen before," said Roger Unger, MD, director of the Touchstone Center for Diabetes Research at UT Southwestern and the study's senior author. "There's no precedent for a cell that appears like this."

Collaborating with researchers at the University of Geneva Medical School, who conducted morphological tests to analyze the form and structure of the cells, the scientists found that the cells were crowded with mitochondria instead of containing fat.

Researchers examined laboratory animals weighing between 280 and 300 grams. Some of the study subjects received an intravenous injection of the leptin gene, which was expressed in and produced by the liver; the leptin level rose 50 times greater than normal in rats after two to four days before tapering off. The remaining laboratory animals followed a restricted diet.

Animals receiving the injection experienced a rapid and profound loss of fat compared with the animals that followed a restricted diet.

"After 14 days, rats receiving leptin injections plummeted on average from 280 to 207 grams," Dr. Unger said, or about 26 percent of total body weight.

While the rats receiving the leptin injections were healthy, active, and had a decreased appetite, the animals that followed a restricted diet were constantly searching for food and experienced reduced physical activity.

The animals fed a restricted diet also gained back their weight faster than animals receiving the leptin injections.

April 2004 Texas Medicine Contents
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