Cover Story - June 2007
By Crystal Conde
A 9-year-old boy visits his pediatrician's office, his parents concerned by a recent bad report card. The boy's teacher, parents, and doctor discover he can no longer grip a pencil because his hands are too obese. Keeping up with his classmates during recess and simply kneeling down to tie his shoes prove difficult. Not to mention, he's teased for his physical appearance and is withdrawn in social settings among peers. Worse, tests show he has type 2 diabetes.
This scenario isn't uncommon. Often, children and adults don't seek medical attention for their weight problems until they're unable to function normally day to day or chronic diseases have set in.
In the wake of an epidemic taking a toll on health care spending and weighing on the well-being of Texas residents, physicians are working to prevent obesity. And they're calling for collaboration among government organizations, teachers, parents, community leaders, and employers to curtail the rapidly rising rate of obesity.
Texas Comptroller of Public Accounts Susan Combs released a report in March that expounds upon what physicians have known for at least a decade: Texans, both young and old, are growing fatter. Counting Costs and Calories: Measuring the Cost of Obesity to Employers is 54 pages of sobering information on the obesity epidemic threatening Texas, its direct and indirect costs for employers, and its effect on children.
The top five findings in the report are:
- Texas businesses spent an estimated $3.3 billion in 2005 on costs related to obesity, such as disability, decreased productivity, absenteeism, and health care.
- Nearly two-thirds of the state's adults are overweight or obese. Twenty-seven percent of Texas residents were classified as obese in 2005.
- Of Texans between ages 18 and 29, 53.3 percent were overweight or obese in 2005. The prevalence increased among 30- to 44-year-olds at 67.3 percent, and adults 45 to 64 claimed the heaviest share with 71.3 percent. If the rate continues, 48.2 percent of Texas adults will be obese by 2025.
- Estimates place the state's total health care expenditures in the neighborhood of $114 billion, with private insurance for adults accounting for 25.7 percent of that amount, or $29.3 billion. Obesity helps drive those costs.
- From a nationwide standpoint, the U.S. Centers for Disease Control and Prevention reports Texas ranked 10th in 2005, with 64.1 percent of the state's population classified as overweight or obese.
To download the full report, visit the Texas Comptroller of Public Accounts Web site.
Calling obesity a detriment to the financial future of the state, Comptroller Combs is a self-described believer in preventive health care. She commends the medical profession for battling obesity, educating patients about diet and exercise, and implementing public health initiatives.
"We must stem the tide of this awful flood, because if we don't, we're going to drown," she says. "It's avoidable. None of this is inevitable. It's criminal what we're doing to our children. We're feeding them to death."
To help make an impact early on, Comptroller Combs has focused many of her efforts on children. She made strides in school nutrition policy as agriculture commissioner from 1998 to 2006 and was instrumental in instituting the Texas Public School Nutrition Policy, which limits elementary, middle, and junior high school students' accessibility to foods of minimal nutritional value.
In March 2006, the American Medical Association presented Comptroller Combs with the Dr. Nathan Davis Award for Outstanding Government Service, AMA's highest award for a public official, for her antiobesity efforts.
The Texas Medical Association is addressing the problem of childhood obesity in the state by focusing on advocacy, community education, public policy initiatives, and physician education. (See " TMA Supports Obesity Legislation.")
In addition, TMA is urging U.S. Sen. John Cornyn (R-Texas) to cosponsor S 771, the Child Nutrition Promotion and School Lunch Act. The bill would update the U.S. Department of Agriculture's nutrition standards, which are nearly 30 years old, so they conform to current nutrition science and address child health and nutrition at school.
Robert Morrow, MD, chair of TMA's Council on Public Health, says obesity should be treated as a disease that's an epidemic, and the public, as well as government officials, should be educated on obesity's negative long-term effects on society. "We need to keep this on the front burner. It's not as sexy as wiping out avian flu, but the effects are just as far-reaching," he said.
Weighing the Costs
In addition to damaging the health and well-being of the population, the obesity epidemic is driving up costs at the state and national levels. Obesity increased health care spending 36 percent and medication expenditures 77 percent, according to a 2002 study of 18- to 65-year-olds. In Texas, obesity cost businesses nearly $1.4 billion in 2005.
In addition, Counting Costs and Calories reports that in 2005, total U.S. health care spending reached nearly $2 trillion, or $6,697 per person. Obesity and its comorbidities play a role in the increase in insurance premiums. The U.S. Department of Health and Human Services reports that average employment-based health insurance premiums in Texas increased 29.3 percent overall.
While employers and consumers are paying more for health insurance, physicians aren't seeing an increase in reimbursement for preventive services related to obesity. Eduardo Sanchez, MD, director of the Institute for Health Policy at The University of Texas School of Public Health, says many physicians lack the time necessary to monitor and counsel obese and overweight patients, and they often receive inadequate reimbursement from insurance companies for these preventive services.
Having served as commissioner of the Texas Department of State Health Services (DSHS) from 2001 to 2006, Dr. Sanchez recognizes the need to evaluate tax investments in obesity prevention programs while gathering evidence to determine whether the programs are effective. But tracking and measuring data poses a challenge. In addition to the direct costs of obesity in the form of health insurance premiums, the epidemic also has indirect costs such as absenteeism, reduced productivity at work or school, and disability.
"It has always been difficult to prove preventive medicine's worth in general. There hasn't been an overabundance of great research to prove that," Dr. Morrow added.
A Growing Problem
Working around time constraints and inadequate reimbursement is only a fraction of obesity's toll. Physicians also are seeing an increase in the number of obese children. According to the Counting Costs and Calories report, 42 percent of Texas fourth graders, 39 percent of eighth graders, and 36 percent of 11th graders were overweight or at risk of becoming overweight in 2005. And if the rate continues, the future health of these schoolchildren isn't any brighter; the report projects that 70 percent of overweight children will become overweight or obese adults.
Recognizing the need for a preventive approach to obesity and the detrimental impact the epidemic was having on the state, DSHS convened a 20-member Statewide Obesity Task Force in 2003 that studied weight data and analyzed obesity treatments. TMA is part of the task force, which produced a plan that outlined strategies for increasing obesity awareness and promoting fitness at home and in schools, as well as promoting policies that support healthy eating habits.
The original plan has been revised and published as the Strategic Plan for the Prevention of Obesity inTexas : 2005-2010 . The goals are the same, but the updated plan targets diet and exercise among middle school, junior high, senior high, and college students, as well as health promotion program participation rates among Texas employers. To read the full plan, visit www.eatsmartbeactivetx.org. Click on Strategic Plan to download the document.
Stephen Ponder, MD, CDE, a pediatric endocrinologist and director of the Children's Diabetes and Endocrine Center of South Texas at Driscoll Children's Hospital in Corpus Christi, sees the obesity problem every day. He is witnessing an alarming trend: Children are becoming obese earlier, often before they reach school age. They're also being diagnosed with type 2 diabetes. (See " One Doctor's Mission.")
Kimberly Avila Edwards, MD, an Austin pediatrician, faces the same reality. "On a personal level, I think there's a burden on physicians," she said. "It's heartbreaking to see these children come in with these conditions that typically were only found in adults. If we do nothing, these children in their 20s and 30s are going to have heart failure and are going to be dying in their 40s."
The Texas Pediatric Society (TPS) formed an obesity task force of its own in 2003 to help physicians manage their obese patients' health. Dr. Edwards, along with general practitioners, and subspecialists across Texas, joined the task force.
"I finished residency in 2002," Dr. Edwards said. "When I started private practice, I noticed firsthand the significant problem obesity posed. I felt unprepared with respect to the evaluation and counseling of these patients. I lacked the training to manage these patients. When the obesity task force got together, we acknowledged that many physicians were facing the same dilemma."
The task force created a toolkit available for purchase through TPS. The book serves as a diagnosis and treatment overview for physicians and includes an evaluation form, SAFE posters in English and Spanish, patient handouts in English and Spanish that provide nutrition, behavioral, and lifestyle guidelines, English and Spanish healthy lifestyle "prescription" forms, and a body mass index (BMI) wheel to calculate BMI percentile by age and gender. The toolkit can be purchased online at www.txpeds.org. On the home page, scroll down to Childhood Obesity Toolkits, and open the PDF order form.
Susan Strate, MD, a Wichita Falls pathologist and the chair of TMA's Council on Socioeconomics, shares the concerns over the shorter life expectancy for obese children. "We've made so much progress in increasing life expectancy. We may go backward if we don't get control of the obesity epidemic," Dr. Strate said.
To make progress in fighting obesity, it's important for physicians to involve patients' families in its prevention and treatment. For Dr. Edwards, working with the parents of overweight children can be half the battle. "Some parents may see weight as being a personal decision," she said. "I still think parents see it as an affront when schools say you can't have sodas anymore. It's not solely a cosmetic problem, but it's a health problem."
Adding to the problem are socioeconomic factors, such as a lack of safe recreational facilities in economically disadvantaged communities or a lack of education about healthy eating habits.
Dr. Sanchez notes that childhood obesity does seem to be disproportionately aggregated toward lower socioeconomic classes. "What we're finding is that low socioeconomic status in a family predicts low education attainment," he said. "The higher poverty rates among Latinos and African Americans show that race and ethnicity seem to correlate with low education attainment."
The growing prevalence of obesity among adults also plays a role, as children share their parents' diets, according to Dr. Sanchez. He says a long-term investment in prevention is key. "It's a vicious cycle, and the intervention is about … ensuring that all kids graduate from high school and therefore increase the chance that they will be healthy adults -- ones with jobs that provide insurance, as well," he said. "It's a challenge, but I don't think it's an insurmountable challenge. Childhood obesity is the canary in the coal mine."
Dr. Strate says that a multipronged, collaborative approach is necessary in tackling the obesity epidemic. "There's not any one change that's going to work to solve this problem," Dr. Strate said. "Some people don't realize that a freight train is headed toward us. If we don't get control of the obesity epidemic, we're going to face some serious problems. Obesity is the epidemic that is going to cause a huge health care expenditure crisis. If we think health care spending is going up now, just wait to see the economic impact if we don't curb the obesity epidemic. It's not sustainable."
Crystal Conde can be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by-email at Crystal Conde.
One Doctor's Mission
To reach the South Texas community, Corpus Christi pediatric endocrinologist Stephen Ponder, MD, CDE, set out last year to take action at the local level. Counting Costs and Calories: Measuring the Cost of Obesity to Employers breaks down the obesity rate among adults by public health administrative regions designated by the Texas Department of State Health Services. The Upper South Texas and Lower South Texas regions had the highest rates of obesity, at 31.1 percent and 37.4 percent, respectively, in 2005.
To curtail the obesity trend among children, Dr. Ponder helped create the South Texas Obesity Project (STOP) in conjunction with Driscoll Children's Hospital. By bringing together businesses, governmental organizations, physicians, school board members, faith-based groups, and nongovernmental organizations, STOP aims to provide families with greater access to nutrition information, while making them aware of the obesity problem and its consequences.
The groups have formed committees and have held two stakeholder meetings and one planning meeting so far. The committees will put together a final report to create a road map for change in the community. "Obesity is a national problem. We have to think nationally and act locally," Dr. Ponder said. "We can't rely on Washington, D.C., to solve this. We need to organize ourselves … to see significant change in obesity."
In prescribing a mission of prevention, Dr. Ponder recognized in 1999 that physicians needed resources to educate young patients and their parents about common traits and lifestyle choices that contribute to obesity. He developed a concept to help other practitioners manage the health of their overweight child patients while addressing eating habits and lifestyle modifications with parents.
"It was a realization that doctors have very little time to address the comprehensive amount of information that one would have to discuss obesity prevention," Dr. Ponder said. The message is a simple, easy-to-remember acronym, SAFE: Skip or stop high-calorie drinks, Alter your snack habits, Forget fast food, and Exercise daily.
To spread the word, in 2002, the program expanded, and Dr. Ponder worked with Driscoll Children's Hospital to develop a media campaign.
"The tools we developed with this that seemed to work the best are the small posters doctors can put up on the walls of their offices," he said. The SAFE posters and brochures spark dialogue among doctors and parents. By streamlining office visits with the use of SAFE materials, physicians are able to focus on health risks, lowering the threshold for parents who may be hesitant to discuss their children's weight problems.
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TMA Supports Obesity Legislation
At press time, TMA was backing the following obesity-related bills in the Texas Legislature:
- Senate Bill 10, the Medicaid reform bill, which was passed by the Senate. Among its provisions is directing the Health and Human Services Commission to create incentive programs such as smoking cessation or weight loss programs that would promote healthier lifestyles among Medicaid clients.
- Senate Bill 530 and its companion, House Bill 1257, which transfer authority over rulemaking on daily physical activity from the State Board of Education to the Texas Education Agency (TEA). SB 530 strengthens the definition of physical activity to "moderate or vigorous" and restores the 30-minute requirement as a daily minimum. It also requires that physical fitness assessments of K-12 students be conducted two times a year and that school districts compile results and provide a summary by grade level to TEA. SB 530 directs TEA to analyze the results by school district, correlating results to student academic achievement levels, attendance levels, obesity, disciplinary problems, and school meal programs.
- House Bill 3618, which requires TEA to adopt criteria to require that at least one of the approved coordinated school health programs be designed to prevent and detect obesity and type 2 diabetes by taking into account the needs of school districts located in counties on the Texas-Mexico border that have student populations identified as at risk. All program components must contain bilingual materials. Every student in grades K-8 must be measured for height and weight at the beginning of the school year and a second time during the year. The evaluation and analysis of students' progress will aid in determining the effectiveness of the program.
- Senate Bill 1202 requires TEA to establish a pilot program for the prevention of obesity in children attending public schools in three geographic regions of the state. Regions should be selected based on the degree to which children in the region are at higher-than-average risk of developing diabetes; TAKS scores being lower than the state average; and whether more than one-third of students are educationally disadvantaged. Requests for proposal will be issued to private and public entities.
You can access TMA's 2007 legislative agenda on the TMA Web site.
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