Cover Story - March 2009
Tex Med. 2009;105(3):18-27.
By Crystal Conde
Curing much of what ails many Texans seems simple: Eat right, exercise, and don't smoke. Findings from a recent report by United Health Foundation, the American Public Health Association, and Partnership for Prevention, however, illustrate how far the state's residents deviate from following those straightforward guidelines.
The results of America's Health Rankings: A Call to Action for Individuals & Their Communities 2008 Edition are daunting. What stands out is that in just one year Texas has plummeted nine spots from 37th to 46th in terms of overall health of its residents.
Among its findings, the report shows Texas is losing ground in the fight against the obesity epidemic and in its efforts to curtail smoking.
In 1990, according to the report, adult smokers accounted for about 30 percent of Texas' population. The prevalence of smokers dropped to 17.9 percent in 2007, but increased in 2008 to 19.3 percent. The report did not say why.
While the rise in smokers may not seem that alarming, Eduardo Sanchez, MD, vice president and chief medical officer of Blue Cross and Blue Shield of Texas, says the state shouldn't become complacent.
"It's an ongoing effort to keep folks from taking up tobacco. It is really no different from responding to other public health disasters like a hurricane or a disease outbreak. Smoking is more insidious, but we always face an unrelenting set of pressures that can lead people to take up smoking," the former commissioner of the Texas Department of State Health Services (DSHS) said.
The report also says that the rate of obesity in Texas increased from 26 percent to 28.6 percent in the past year. The state's obesity rate was only 12 percent in 1990.
Kimberly Edwards, MD,an Austin pediatrician and chair of the Texas Pediatric Society Obesity Committee, says the state's obesity rate increase isn't shocking. She says physicians have come to expect having to treat complications of obesity such as heart disease and type 2 diabetes in children. (See the February 2009 Texas Medicine symposium issue on the emergence of adult diseases in children.)
"When it comes to obesity, it's a challenge to know how or to be able to treat these kids. There are a number of hurdles physicians have to jump over," she said. "Not all physicians have all the answers, and they're not the only ones to come up with solutions. But I think they're integral to finding the solutions."
Indeed, Dr. Edwards and other physicians recognize that a new approach to public health in Texas will involve grassroots community efforts, work by physicians to modify patients' lifestyles and behaviors, financial investment in preventive medicine by the state, and adoption of evidence-based public health programs across the state. The Texas Medical Association is working with public health organizations and other groups during this legislative session to pass laws that will reduce the rates of obesity and tobacco use statewide. (See "TMA, Public Health Coalition Legislative Recommendations.")
About the Survey
America's Health Rankings examines a number of health determinants, including personal behaviors, community and environment, public health policies, and clinical care.
Specifically, the report evaluates a state's:
- Prevalence of smoking, binge drinking, and obesity;
- High school graduation rate;
- Violent crime;
- Occupational fatalities;
- Children living in poverty;
- Air pollution;
- The uninsured population;
- Funding of public health;
- Immunization rates of children aged 19-35 months;
- Adequacy of prenatal care;
- Number of primary care physicians; and
- Preventable hospitalization of Medicare enrollees.
Separately, the report looks at health outcomes encompassing "poor mental and physical health days," geographic disparity, infant mortality, and cardiovascular, cancer, and premature deaths. The report measures "poor mental health days" by looking at the number of days in the previous 30 days in which a person indicates limited activities due to mental health difficulties. The report evaluates "poor physical health days" the same way.
The America's Health Rankings reports have been published annually for 19 years. In the past four years, findings indicate the overall health of the nation hasn't improved.
The report also sheds light on some areas of public health in which Texas has improved. These include decreased infant mortality rate -- from 9.3 deaths per 1,000 live births in 1990 to 6.5 in 2008 - and in infectious diseases - from 47.8 per 100,000 in 1990 to 23.8 in 2008. In addition, immunization coverage for Texas children aged 19-35 months has increased 15 percent since 2003 to approximately 78 percent.
TMA's Be Wise - Immunize SM initiative, funded through a grant from the TMA Foundation, works to increase statewide vaccination rates through education, communication, and action. During an August Be Wise - Immunize vaccination blitz, more than 5,700 Texas children received vaccinations. .
The full report and the state-by-state results of American's Health Rankings are posted online .
The report isn't without a critic. DSHS recognizes that Texas has public health challenges. But, according to Doug McBride, DSHS press officer, the department prefers not to comment on the America's Health Rankings report.
"While the annual assessments and measurements in the America's Health Rankings report can be useful … we find the practice of ranking the states questionable and misleading," Mr. McBride said.
He cites data from the report pertaining to "poor physical health days" as an example. Texas went from a value of 3.3 days in the 2007 report to 3.8 days in the 2008 report in this category.
"This change is statistically insignificant in that it falls within the 95-percent confidence interval (margin of error) for the data on which we believe the 3.3 and 3.8 values were based. In other words, the value could have actually been 'no change,' yet Texas' ranking in the category fell from 17th to 41st," he said.
Mr. McBride also says the factors assessed in the report have little or nothing to do with the work of DSHS, making the department "reluctant to be the governmental face for erroneously implied poor performance."
The America's Health Rankings report includes data from numerous public and private entities. They include the American Medical Association; U.S. Department of Health and Human Services; the Centers for Disease Control and Prevention's (CDC's) Behavioral Risk Factor Surveillance System; National Center for Health Statistics; the Commerce, Education, and Labor departments; U.S. Environmental Protection Agency; The Dartmouth Atlas Project; Trust for America's Health; and World Health Organization.
Why Texas Is Struggling
Dr. Edwards and Dr. Sanchez say the report's results don't surprise them.
The state's ability and willingness to invest in effective, population-based health measures continue to fall short, Dr. Sanchez says. According to the 2008 America's Health Rankings report, Texas ranks 42nd in public health funding, investing only $47 per person. The average in the United States is $88 per person.
Jeffrey Levin, MD, MSPH,chair of the TMA Council on Public Health, says Texas faces a challenge in prioritizing funds for prevention. But, he says, the state should focus on heading off disease early on.
"Our processes compel us or drive us to look at what the immediate one-year return on investment is," he said. "We know that an effective, aggressive focus on nutritional programs and exercise at an early phase of life makes a difference. Comprehensive campaigns to reduce smoking and increase cessation are effective, but they require some investment on the front end. There's a cost, but the long-term gains are substantive."
One area of public health in which Texas woefully lags is implementing an effective, comprehensive tobacco prevention program. (See "Up in Smoke," December 2007 Texas Medicine , pages 20-28.) CDC recommends Texas invest $266.3 million in such a program this year. During fiscal year 2008, Texas poured only $12.9 million into tobacco prevention. And this year it will invest a meager $13.8 million.
The Texas Public Health Coalition, of which TMA is a charter member, supports funding to enable DSHS to conduct a statewide tobacco control program that would include state, community, and school-based interventions, as recommended by CDC.
State public health officials and some lawmakers recognize that investing $3 per capita, or approximately $68 million, in a statewide program would result in about 163,600 fewer smokers in Texas. Five years after implementation, the state would save $1.4 billion in avoided medical care costs and regained productivity. That's according to a Kaiser Permanente study that examined a tobacco prevention pilot program in Southeast Texas.
In 2000 and 2001, the state managed tobacco prevention pilot programs in 18 East Texas communities. Port Arthur launched the most robust program by investing $3 per capita. The program worked. Port Arthur reduced smoking by 40 percent among sixth and seventh graders. In addition, tobacco use among youths in grades six through 12 declined from 35 percent to 21 percent in Jefferson County as a whole. In the same region, tobacco use decreased from 35.7 percent to 26.6 percent among adults aged 18 to 22 from 2000 to 2004.
The 2002-03 state budget included $12.5 million per year to expand the program. The return on the investment was evident. The DSHS report Progress on Achieving Texas Tobacco Reduction Goals: A Report to the 80th Legislature states that by investing $3 per capita, or approximately $4.3 million, in 2003 alone, the region saved more than $252 million in medical care costs and lost productivity. The initiative also resulted in 29,800 fewer adult smokers.
The state legislature didn't continue to fund the comprehensive program, however. A decrease in prevention funding for fiscal year 2004-05 reduced the investment to less than $3 per capita in a majority of counties.
According to Dr. Edwards, the state's challenges in reducing obesity rates relate to the current medical landscape and low or no reimbursement from insurance companies for preventive services.
She says that, for starters, physicians must see so many patients each day that they lack the time necessary to diagnose and counsel patients who are overweight or obese.
Another hurdle Dr. Edwards identifies is the failure of many insurance companies to recognize obesity as a medical condition. She says insurance companies may not be willing to reimburse physicians for preventive efforts such as counseling; they'll begin reimbursing once patients develop high cholesterol or some other obesity-related illness.
Dr. Levin agrees. He says the health care system needs to invest financially in the patient-physician relationship by rewarding physicians for their prevention efforts.
"People have a greater tendency to trust and take the advice of their physicians. That means getting to know the patient and going over the problems with the patient. That doesn't always translate to a monetary return. The more time spent counseling patients, the less physicians are able to earn and support their practices," he said.
The Partnership for Prevention's report Why Invest? Recommendations for Improving Your Prevention Investment says lifestyle modification, such as antitobacco and alcohol programs, rank highly for preventive impact and financial value, but less than 25 percent of employers offer them. Because few health care payment plans cover tobacco cessation counseling and medications, few physicians receive payment for the services.
Partnership for Prevention reports that counseling adult patients who smoke saves about $500 per smoker. The organization also says that in 2005 health care professionals provided only 27.5 percent of smokers with medication assistance to quit smoking or any intervention to quit.
At press time, TMA's Council on Health Promotion was evaluating the American Medical Association's Healthier Life Steps Program, which guides physicians in working to change patients' diet, physical activity level, alcohol consumption, and tobacco use. The program includes materials for physicians and a comprehensive toolkit for patients. (See " Resources Help Physicians Change Patients' Behavior.")
TMA supports a law prohibiting smoking in public places statewide. In January, Rep. Myra Crownover (R-Denton) filed House Bill 5 to eliminate smoking in all indoor public and private workplaces, including restaurants and bars.
"This bill will save lives, save taxpayers money on health care, and is good for business. We tell businesses all the time how many fire exits to have and what sprinkler systems must be installed at great expense to business. This legislation will save thousands of lives at no cost to business or to Texas," she said.
The state of New York is a case study in immediate positive health outcomes from a statewide smoke-free law. Researchers in a November 2007 article in the American Journal of Public Health report that admissions for acute myocardial infarction (AMI) at New York hospitals declined after the state passed a comprehensive smoke-free law in 2003.
AMI admissions decreased 8 percent, with 3,813 fewer hospital admissions in 2004. Direct cost savings totaled $56 million the same year.
Massachusetts has benefited from a statewide smoke-free law, as well. Nearly 600 fewer residents have died from heart attacks each year since legislators banned smoking in virtually all restaurants, bars, and other workplaces five years ago.
During the 2007 session of the Texas Legislature, TMA backed HB 9 by Representative Crownover and Senate Bill 368 by Sen. Rodney Ellis (D-Houston). As filed, the bills would have eliminated smoking in all public and workplaces, as well as seating areas of outdoor venues. They also would have prohibited smoking within 15 feet of an entrance, an operable window, or a ventilation system of an enclosed nonsmoking area.
To win support, amendments to the original bills exempted cigar bars and tobacco shops and reduced certain penalties. Despite the weakened provisions, the bills died on the Senate floor.
Joel Romo, American Heart Association regional vice president of advocacy, hopes the legislature will succeed in eliminating tobacco smoke from Texas' air. He points to a 2007 survey by Baselice & Associates Inc. that shows 66 percent of Texas voters want no-smoking designations in public buildings, offices, restaurants, and bars. Thirty percent of those polled oppose such a statewide law.
Further strengthening support for a statewide smoke-free law, Mr. Romo says, is recognition by legislators and their staffs of the health benefits of smoke-free ordinances in cities across Texas. In the past, opponents argued that smoke-free ordinances were bad for business. Mr. Romo says that on average, restaurant and bar revenues increase after about six to eight months of having these ordinances in place.
"Our polling shows more people are willing to go to restaurants and other public venues with their families if the environments are smoke-free," Mr. Romo said.
In fact, a one-year assessment of the impact of a smoke-free law on restaurant and bar revenues in El Paso indicates gross restaurant and bar, restaurant-only, and bar-only revenues continued to increase after that city's 2002 no-smoking ordinance.
Corpus Christi and Dallas are the most recent cities to adopt smoke-free ordinances. The Corpus Christi City Council approved an ordinance prohibiting smoking in bars, bowling alleys, and pool halls and extended an existing ban in restaurants and most public places. The Dallas City Council voted to make all indoor public places and workplaces, including freestanding bars and billiard halls, smoke-free. Both ordinances take effect in April.
A statewide smoke-free law would reduce direct and indirect costs associated with tobacco-related diseases, and, Mr. Romo adds, would not require any financial investment up front.
"The return on investment is a healthier workforce, fewer absences, and a cost savings to the state of Texas. A lot of these folks end up on the tax rolls when they need medical care due to the use of tobacco products," Mr. Romo said.
Texas spends $1.5 billion annually on Medicaid funding directly related to smoking.
Working to Reduce Obesity
Obesity projections presented by Texas State Demographer Karl Eschbach, PhD, at the Partnership for a Healthy Texas Obesity Health Policy Forum in December associate the state's increase in obesity with population growth and aging, race and ethnic shifts, and ongoing lifestyle changes.
Moderate projections estimate the number of obese Texas residents by 2040 will be approximately 14.65 million, or nearly 43 percent of the population. By 2040, this scenario estimates the percentage of obese whites at 32 percent, while the percentage of obese African-Americans and Hispanics will reach about 50 percent and 49 percent, respectively.
"These numbers are meant to be both scary and a challenge," Dr. Eschbach said at the forum. "We're presenting very conservative projections. Now it's time to make the changes that will arrest the trends."
According to Dr. Sanchez, the higher rate of obesity among Hispanics goes beyond race. He asserts that populations with less education are more likely to live in poverty, less likely to have health insurance, and will have worse health outcomes. Research backs him up.
The 2006 Kaiser Commission on Medicaid and the Uninsured found that those "with low levels of education are considerably less likely to have health insurance; they are also more likely to have only limited or erratic coverage or to be uninsured for long periods of time."
Moderate projections showing the prevalence of obesity in various regions of the state magnify the problem along the border, in some parts of East Texas, far West Texas, and the Panhandle. By 2020, Dr. Eschbach predicts, the prevalence of obesity will reach more than 33 percent in those areas, especially along the Texas-Mexico border.
Gilberto A. Handal, MD, a member of TMA's Committee on Child and Adolescent Health and an infectious diseases specialist in El Paso, is all too familiar with the challenges affecting obesity in the border region. He says the education system, health care system, and community must work together so their impact on obesity can be pervasive, continuous, and relentless. (See the February 2007 Texas Medicine symposium issue on border health.)
"I truly believe that a problem that's long-term can't be looked at like a crisis. My problem is the educational system thinks in a different way than the health care system," he said. "We have compartmentalized the issues. The issues affecting our children are complex. We can't separate the child's socioeconomic situation or culture from the educational or health care process."
Dr. Handal advocates a comprehensive, sustained, well-funded approach to combating obesity. He says when people from Mexico move to the United States they often alter their eating habits to include unhealthy fast foods. Dr. Handal has witnessed activity levels decrease among people living in low-income areas that lack parks, recreation areas, and bike routes. This leads residents of these neighborhoods to adopt sedentary lifestyles that contribute to obesity.
Obesity is weighing on the state's financial well-being, too. Counting Costs and Calories: Measuring the Cost of Obesity to Employers , a 2007 report by the Texas Comptroller of Public Accounts, estimates obesity cost Texas businesses $3.3 billion in 2005. And estimates place the state's total obesity-related health care expenditures in the neighborhood of $114 billion. (See " The Obesity Threat," January 2009 Texas Medicine, pages 29-34.)
Physicians also can make a difference in preventing and reducing its threat to the public.
"The uplifting message is that physicians are seen as credible sources of information and guidance. We physicians shouldn't shy away from that opportunity. And we should be sure to recommend programs and treatments that have evidence to back them up," Dr. Sanchez said.
But Dr. Edwards says the evidence base for preventing obesity and modifying lifestyle behaviors is still evolving and disjointed.
"It's going to have to be a community effort that inspires this change. A lot of people care, but it's fragmented. We need cohesion among the stakeholders. The recognition of what each part is doing isn't there yet. We all need to speak the same language and use the same data," she said.
CDC recognizes this disconnection, and its Division of Nutrition, Physical Activity, and Obesity is working to reduce obesity and obesity-related conditions, in part, through translation of practice-based evidence and research findings.
For instance, the CDC's Weight Management Research to Practice Series online summarizes the science behind weight management and highlights the implications of the research findings for public health and medical care professionals.
What Physicians Can Do
Dr. Edwards recommends physicians get involved with agencies outside medicine. She's working with the Texas Parks and Wildlife Department to facilitate more opportunities for children's outdoor activities.
She also is collaborating with Stephen Pont, MD, MPH, an Austin pediatrician, on implementing a multidisciplinary approach to treating overweight and obese children called Healthy Living, Happy Living. Based on a curriculum developed in California called KidShape, their approach brings mental health professionals, physical education instructors, nutritionists, and pediatricians together in one setting.
The program, presented in English and Spanish, launched in January at UT Elementary School and targets students and their parents in East Austin. Dr. Edwards' long-term goal is to help start a center for the prevention and treatment of obesity in Austin.
In the physician's office, Dr. Edwards recommends doctors use a technique called motivational interviewing to assess and empower their patients to make positive health changes. Physicians guide their patients toward making these changes through carefully eliciting discrepancies between patients' health goals and their current lifestyles and by enhancing their patients' confidence and commitment to change.
Dr. Edwards was part of the Texas Pediatric Society (TPS) Obesity Task Force in 2003. Primary care physicians and subspecialists across Texas put together a pediatric obesity toolkit to aid physicians in diagnosing and treating obese children. Dr. Edwards says physicians need to make screening a priority. In her practice, she's seeing children as young as 2 who are overweight or obese.
"The earlier you start, if you notice body mass index [BMI] going up at age 2, you have more opportunities for change. It might be more difficult to influence lifestyle changes at age 15 when they're way above the normal BMI chart," she said.
Obesity and smoking prevention are valuable in the child population, but they're public health concerns affecting adults, as well. Dr. Sanchez says when treating adults, physicians should assess readiness for change. The AMA's Healthier Life Steps Program helps medical professionals modify patients' behaviors.
In addition, Dr. Sanchez advises physicians to look into whether a patient's health care payment plan or employer offers benefits for smoking cessation counseling or prescriptions, as well as weight reduction programs or health club memberships.
Time for a New Approach
The sobering results of the America's Health Rankings report support the push for a new approach to public health in the state, according to Dr. Edwards.
"We need more focus on prevention. We're creating programs and doing a lot for overweight and obese kids who are already dealing with the problem. I believe schools have a role to play, but we can't start at the schools. We have to start younger, when women are pregnant. It's a radically different approach to medicine," she said.
Dr. Levin agrees that a new, comprehensive approach to solving Texas' public health problems is necessary. He likens the public health challenge of obesity to the energy crisis the country faces.
"We know what needs to be done. We need to use less energy and come up with alternative sources. A similar approach is needed to solve the obesity epidemic. We need to eat less and figure out how to incorporate greater levels of exercise," he said.
Mr. Romo says a more aggressive approach to smoking prevention and cessation would make a difference in Texas by reducing the number of children and adults who use tobacco products. The Texas Public Health Coalition is calling for more funding that would allow DSHS to implement a comprehensive statewide tobacco control program and funding to make smoking cessation programs available through the Employees Retirement System of Texas.
"By making this investment, the legislature would demonstrate the need for people to quit tobacco and prevent its use," he said.
Transferring public health attention to prevention in the state of Texas will require considerable effort by physicians, community leaders, lawmakers, and the public, Dr. Sanchez says.
"We need a willingness to roll up our sleeves and do the work to make a difference. The evidence is fairly compelling. Our declining health status is evident," he said. "We need to understand the value of funding. If you can invest $10 and prevent $100 worth of conditions, that's a reasonable investment. Failing to invest the $10 initially and spending the $100 later on to treat the conditions isn't."
Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email at Crystal Conde.
TMA, Public Health Coalition Legislative Recommendations
The Texas Medical Association's recommendations to the 2009 legislature for a smoke-free Texas are:
- Support legislation to prohibit smoking in public places, and
- Support tax incentives for employers to reward nonsmokers and encourage smokers to participate in tobacco cessation programs.
TMA is a charter member of the Texas Public Health Coalition, which developed these legislative priorities for a smoke-free Texas:
- Support funding to enable the Texas Department of State Health Services (DSHS) to implement a comprehensive statewide tobacco control program that would include state, community, and school-based intervention programs, as recommended by the Centers for Disease Control and Prevention;
- Support funding for and a directive to make comprehensive smoking cessation programs (including pharmacological therapy) available to all employees and beneficiaries of the state of Texas through the Employees Retirement System of Texas; and
- Support funding from the Cancer Prevention and Research Institute of Texas to promote policies and programs to reduce tobacco use and exposure to secondhand smoke.
TMA's recommendations to the 2009 legislature for battling obesity are:
- Support funding to improve education on the importance of proper nutrition and physical activity;
- Support legislation and funding for a coordinated school health program in all grade levels; and
- Encourage health plans to promote healthy lifestyles by encouraging members to seek diagnosis and treatment for weight-related conditions.
TMA also backs the Texas Public Health Coalition's legislative priorities for obesity prevention:
- Support legislation and funding for the Texas Department of Agriculture's (TDA's) Public School Nutrition Policy efforts to meet or exceed the 2005 Dietary Guidelines for Americans for all reimbursable and nonreimbursable meals;
- Support TDA's request to promote and reward the implementation of best practices in nutrition education in schools and early childhood environments, as part of the collaborative effort with the Texas Education Agency and DSHS;
- Support legislation and funding for physical activity programming in early childhood environments and all grade levels and support school environments that promote physical education;
- Support funding for DSHS's request to reduce the impact of chronic diseases through prevention of obesity, heart disease, and stroke;
- Support efforts to broaden and expand employees' access to worksite wellness; and
- Support funding from the Cancer Prevention and Research Institute of Texas to focus on policies and programs aimed at addressing cancer risk related to obesity.
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Resources Help Physicians Change Patients' Behavior
The American Medical Association's Healthier Life Steps Program guides physicians in working to change patients' diet, physical activity level, alcohol consumption, and tobacco use. Click here [ PDF ] to download the Physicians' Guide, which instructs doctors in implementing strategies to assess patients' readiness to change and in counseling patients on making changes in their lifestyles.
The toolkit portion of the program fosters one-on-one, in-office communication between physicians and their patients. It provides a self-assessment questionnaire, action plans, progress tracking calendars, and a poster to encourage necessary behavior changes. To download PDFs of the Healthier Life Steps Program's Physicians' Guide and toolkit, click here .
The Texas Pediatric Society (TPS) in 2003 formed its Obesity Task Force to help physicians manage their obese patients' health. The task force created Pediatric Obesity: A Clinical Toolkit for Healthcare Providers , and TPS distributed 15,000 copies to physicians.
The toolkit serves as a diagnosis and treatment overview for physicians and includes an evaluation form; 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 designed to calculate BMI percentile by age and gender.
TPS plans to release the second edition of the TPS obesity toolkit online this month. The revised version features new elements, such as information on motivational interviewing to assess and empower patients' likelihood for positive health change, as well as the recommendations of an expert committee formed in 2007 by the Department of Health and Human Services Health Resources and Services Administration. The recommendations guide health care professionals on the prevention, assessment, and treatment of child and adolescent overweight and obesity, and feature information on motivational interviewing and the steps that can be taken in the prenatal and infancy years to prevent overweight and obesity.
The revised version contains a chapter on the prenatal and perinatal influences on childhood obesity.
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