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Reversing Childhood Obesity in Texas: Bigger is not Always Better

TOMA/TxACOFP Joint Annual Convention 2010 June 19, 2010

Eduardo Sanchez , MD, MPH

VP and Chief Medical Officer, BlueCross BlueShield of Texas

Former, Texas Commissioner of Health

Childhood Obesity:Why We Must Act Now!

Dallas Regional ChamberMay 21, 2010

Eduardo Sanchez , MD, MPHVP and Chief Medical Officer, BlueCross BlueShield of Texas

Former, Texas Commissioner of Health

1. Childhood obesity prevalence is the same today as it was 30 years ago.

a. Trueb. False

Pre Test Questions

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2. The childhood obesity rate in the United States is approximately

a. 1%b. 5%c. 15%d. 50%e. 75%

Pre Test Questions

3. The USPSTF recommends that children six years old and older be screened for obesity and be offered or referred for appropriate intervention.

a. Trueb. False

Pre Test Questions

Ready, Willing, And Unable To Serve (Mission: Readiness)

Physically unfit: 27 percent of young Americans are too overweight to join the military.

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Source: CDC Behavioral Risk Factor Surveillance System.

Obesity Trends* Among U.S. AdultsBRFSS, 2007

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: CDC Behavioral Risk Factor Surveillance System.

Obesity Trends* Among U.S. AdultsBRFSS, 2008

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Causes of Death, United States 2005

Source: cdc.gov

1.4%

1.8%

2.9%

3.1%

4.8%

5.3%

5.9%

22.8%

26.6%

0% 9% 18% 27% 36%

Septicemia

Influenza and pneumonia

Alzheimer’s disease

Diabetes mellitus

Unintentional injuries

Chronic lower respiratory disease

Stroke

All cancers

Diseases of the heart

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The Preventable Causes of Death in the United States:Comparative Risk Assessment of Dietary, Lifestyle, andMetabolic Risk Factors (Danaei,2009)

Deaths attributable to individual risk (thousands) in both sexes

Definition: Levels of Health Literacy

Adequate – understands most reading tasks; misreads only complex information.

Marginal – sometimes misreads instructions and dosages and has difficulty with complex information.

Inadequate – often misreads Rx instructions and appointment slips.

Higher health literacy is correlated with lower mortality rates

Mortality Rates by Health Literacy Levels

“Non-clinical factors affecting mortality

39.4%

28.7%

18.9%

0%

10%

20%

30%

40%

50%

Inadequate Marginal Adequate

Mo

rta

lity

Ra

te

Literacy Level

Note: Based on 3,260 Medicare managed-care who were interviewed in 1997 to determine their demographic characteristics, chronic conditions, self-reported physical and mental health, and health behaviors. Participants also completed the shortened version of the Test of Functional Health Literacy in Adults (S-TOFHLA) that included two reading passages and four numeracy items to assess comprehension of hospital forms and labeled prescription vials that contained numerical information. Main outcome measures included all-cause and cause specific (cardiovascular, cancer and other) mortality using data from the National Death Index through 2003.Source: Baker, DW., et al. (2007) Health Literacy and Mortality Among Elderly Persons. Archives of Internal Medicine 167(14):1503-1509Copyright © 2007 American Medical Association. All rights reserved.

Medical costs due to obesity

Medical costs related to obesity in America in 2008 may be as high as $147 billion.

Average annual medical costs

• Health weight - $3400

• Obese - $4900

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The Impact of Obesity on Rising Medical Spending

27% of the rise in health care spending from 1987 to 2001is accounted for by increases in the proportion of and spending on obese people relative to healthy weight individuals.

Thorpe, et al. Health Affairs, Oct 2004.

Cost of obesity projections(over 10 years by year in $ billions,assuming 5% increase annually)

2009 147

2010 154.35

2011 162.07

2012 170.17

2013 178.68

2014 187.61

2015 197

2016 206.84

2017 217.19

2018 228.05

$1.849 trillion

YEAR COST ($)

STOP Obesity Alliance Survey

Only 39% of patients with BMI of 30 or higher report being told by their physician that they are obese.

90% of them were told to lose weight.

One third of them were not advised how to achieve and maintain a healthy weight.

72% of PCPs say no one in their practice is trained to address weight issues.

64% would like more time.

46% would like to know community resources.

44% would like tools to address obesity.

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11.3%

15.8%

17.5% 17.0%

10.5%

16.0%17.0%

17.6%

0%

4%

8%

12%

16%

20%

1988-1994 1999-2002 2001-2004 2003-2006

Pe

rce

nta

ge

of

Ag

e G

rou

p

Po

pu

lati

on

Ages 6-11 Ages 12-19

One in six children aged six to 19 are now considered overweight, up from just one in 10 only 15 years ago

Prevalence of Childhood Obesity in the United States

Children and AdolescentsConsidered Overweight by Age Group

Note: Overweight is defined as body mass index (BMI) at or above the sex- and age-specific 95th percentile BMI cutoff points from the CDC Growth Charts: United States.Source: Centers for Disease Control and Prevention. Health, United States, 2007 and 2008

Prevalence of Childhood Obesity in the United States

Almost 1/3 of children and adolescents are overweight or obese

11.3% of children and adolescents are very obese (97th

percentile)

Ogden,2008, JAMA, 299(20), 2401-2405.)

Prevalence of BMI > 95% in Boys(Ogden,2008, JAMA, 299(20), 2401-2405.)

Age Range (in years) Whites Blacks Latinos

2-5 11.1 13.3 18.8

6-11 15.5 18.6 27.5

12-19 17.3 18.5 22.1

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Prevalence of BMI > 95% in Girls(Ogden,2008, JAMA, 299(20), 2401-2405.)

Age Range (in years) Whites Blacks Latinas

2-5 10.2 16.6 14.5

6-11 14.4 24.0 19.7

12-19 14.5 27.7 19.9

Prevalence of BMI > 85% in Boys(Ogden,2008, JAMA, 299(20), 2401-2405.)

Age Range (in years) Whites Blacks Latinos

2-5 25.4 23.2 32.4

6-11 31.7 33.8 47.1

12-19 34.5 32.1 40.5

Prevalence of BMI > 85% in Girls(Ogden,2008, JAMA, 299(20), 2401-2405.)

Age Range (in years) Whites Blacks Latinas

2-5 20.9 26.4 27.3

6-11 31.5 40.1 38.1

12-19 31.7 44.5 37.1

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Energy Intake Energy Expenditure

Energy Balance

Individual

Factors

Behavioral

Settings

Social Norms

and Values

� Communities

� Worksites

� Health Care

� Schools and

Child Care

� Home

� Demographic

Factors (e.g., age,

sex, SES,

race/ethnicity)

� Psychosocial

Factors

� Gene-

Environment

Interactions

� Other Factors

� Government

� Public Health

� Health Care

� Agriculture

� Education

� Media

� Land Use and

Transportation

� Communities

� Foundations

� Industry

Food

Beverage

Retail

Leisure and

Recreation

Entertainment

Physical

Activity

Sectors of

Influence

Food &

Beverage Intake

IOM Comprehensive approach for preventing

and addressing childhood obesity

SOURCE: Institute of Medicine, Progress in Preventing Childhood Obesity, 2007, pg 20.

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SOLVING THE PROBLEM OF CHILDHOOD OBESITY WITHIN A GENERATION (May 2010)

Getting children a healthy start on life, with good prenatal care for their parents; support for breastfeeding; adherence to limits on “screen time”; and quality child care settings with nutritious food and ample opportunity for young children to be physically active.

Empowering parents and caregivers with simpler, more actionable messages about nutritional choices based on the latest Dietary Guidelines for Americans; improved labels on food and menus that provide clear information to help make healthy choices for children; reduced marketing of unhealthy products to children; and improved health care services, including BMI measurement for all children.

Providing healthy food in schools, through improvements in federally-supported school lunches and breakfasts; upgrading the nutritional quality of other foods sold in schools; and improving nutrition education and the overall school environment.

Improving access to healthy, affordable food, by eliminating “food deserts” in urban and rural America; lowering the relative prices of healthier foods; developing or reformulating food products to be healthier; and reducing the incidence of hunger, which has been linked to obesity.

Getting children more physically active, through quality physical education, recess, and other opportunities in and after school; addressing aspects of the “built environment” that make it difficult for children to walk or bike safely in their communities; and improving access to safe parks, playgrounds, and indoor and outdoor recreational facilities.

White House Task Force on Childhood Obesity

A tale of two communities

Somerville, Massachusetts

El Paso, Texas

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Lessons Learned from tobacco control initiatives

Comprehensive approaches work best

Single interventions haven’t worked as well

Programs need to be sustained

Steps to prevent and reverse childhood obesity

School-basedUniversal coordinated school health programs

Science based nutrition guidelines for all foods in schools

Universal school breakfast/lunch

Fresh fruits and vegetables

Farm to School

School gardens

30 minutes per day physical activity in schools

Classroom teaching about good eating and activity

No child left behind – 100% high school graduation

Steps to prevent and reverse childhood obesity

Toolkits for clinicians

Physician advocacy

Develop and standardize health/nutrition guidelines for FNS/SNAP/WIC

Summer food programs for eligible children

Community access to good food – healthy, green, just, and affordable

Water over soda

No child left inside

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The Role of Health Plans in Addressing Obesity

Raising awareness and changing attitudes –employers and members

Partnerships

Public policy

Charitable giving

Data sharing

Wellness/Prevention

Decision support tools - toolkits

Aligned reimbursement strategies

BCBSA Pediatric Obesity and Diabetes Prevention Pilot Program

5-2-1-0 message

• 5 servings of fruits and vegetables daily

• limit TV or computer time to 2 hours or less daily

• participate in 1 hour or more of play or physical activity daily

• drink zero sweetened drinks every day

BCBSA Pediatric Obesity and Diabetes Prevention Pilot Program

More than 1,650 physician practices in five states will receive tool kits

The tool kits include

• a pocket guide for the docs,

• charts for physicians to log information,

• a double-sided wall poster,

• tear-off sheets tailored towards different age ranges: ages 2 to 4, 5 to 9, and 10 years and older,

• patient workbooks that allow patients/parents to track their healthy habits and

• tri-fold brochures to help generate awareness and provide parents with basic information about Body Mass Index (BMI), behavioral risks and healthy tips.

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USPSTF

Screening for Obesity in Children and Adolescents (January 2010)

Summary of Recommendation

• The USPSTF recommends that clinicians screen children aged 6 years and older for obesity and offer them or refer them to comprehensive, intensive behavioral interventions to promote improvement in weight status.Grade: B recommendation.

Policy Position Statement on the Prevention, Assessment, Diagnosis and Treatment of Child and Adolescent Obesity in the Healthcare Environment

Assessment:

• Healthcare providers should perform, at a minimum, a yearly assessment of weight status in all children.

• Providers should qualitatively assess dietary patterns, screen time, and physical activity behaviors in all pediatric patients at each well child visit.

• All overweight and obese children should receive a thorough physical examination including BMI assessment, pulse rate and blood pressure measured with a large enough cuff. The following laboratory tests should occur for both the overweight and obese: fasting lipid profile, fasting glucose, aspartate aminotransferase, and alanine aminotransferase. In the obese patient, blood urea nitrogen and creatinine should be assessed.

• Healthcare providers should obtain a focused family history for obesity, type 2 diabetes, cardiovascular disease (particularly hypertension), and early deaths from heart disease or stroke to assess risk of current or future comorbidities associated with a child’s overweight or obese status.

Treatment: For overweight and obese children, treatment should occur in a staged approach based upon the child’s age, BMI, related comorbidities, weight status of parents, and progress in treatment: a prevention plus protocol, structured weight management, comprehensive multidisciplinary protocol, and pediatric tertiary weight management. The child’s primary caregivers and families should be integrally involved in the process.

AHA

Recommendations for Treatment of Child and Adolescent Overweight and Obesity

Bonnie A. Spear, Sarah E. Barlow, Chris Ervin, David S. Ludwig, Brian E. Saelens, Karen E. Schetzina and Elsie M. Taveras

Pediatrics 2007;120;S254-S288

Staged Treatment of Pediatric Obesity According to Age and BMI Percentile

Age groupings

• 2-5 years

• 6-11 years

• 12-18 years

BMI percentile

• 5 - 85

• 85 - 94

• 95 - 98

• > 98

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Local Government Actions to Prevent Childhood Obesity

September 2009

The Childhood Obesity Epidemic

• 16.3% of children and adolescents are obese in U.S. (one in six)

• Obesity rates have tripled in the last 30 years

• While all children are increasingly obese, the poor, African Americans, Latinos, American Indians, and Pacific Islanders are disproportionately more overweight and obese.

Consequences of Childhood Obesity

• May reduce life expectancy

• More likely to develop hypertension, type-2 diabetes, and high cholesterol

• More likely to become obese adults

• Reduced quality of life

• Higher medical expenses

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Evidence Analysis

• Evidence of effectiveness

• Effect size

• Outcomes and externalities

• Potential reach

• Impact and cost

• Feasibility

12 Most Promising Action Steps

• Attract supermarkets and grocery stores to underserved neighborhoods

• Require menu labeling in chain restaurants• Mandate and implement strong nutrition

standards for foods and beverages in government-run or regulated after-school programs

L1

12 Most Promising Action Steps

• Adopt building codes to require access to, and maintenance of water fountains

• Implement a tax strategy to discourage consumption of foods and beverages that have minimal nutritional value

• Develop media campaigns to promote healthy eating and active living

Slide 41

L1 breatk up by goals? spread out more? Meyers, 9/7/2009

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12 Most Promising Action Steps

• Plan, build, and maintain a network of sidewalks and street crossings that creates a safe and comfortable walking environment and that connects to destinations

• Adopt community policing strategies that improve safety and security of streets and parks

• Develop and implement a Safe Routes to

School program

12 Most Promising Action Steps

• Build and maintain parks and playgrounds that are safe and attractive for playing, and close to residential areas

• Establish joint use of facilities agreements allowing playing fields, playgrounds, and recreation centers to be used when schools are closed

• Institute policies mandating minimum play space, physical equipment, and duration of play in preschool, after-school, and child-care programs

Bottom Line Message• Obesity is one of the most serious and

expensive health problems facing our nation• Through their decisions and actions, local

officials either support or undermine efforts to get kids to eat healthy and be active

• Local officials can make it either easy or hard for kids to eat healthy and be active

• Local officials have the power to take steps to significantly cut the rate of childhood obesity

• Childhood obesity is a matter of healthy equity• Act now

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Tackling Obesity and Chronic Disease – start upstream

Better engage physicians

Universal coordinated K-12 school health

Adult wellness (DPP model) – workplace, community, and home

• 30 minutes of physical activity daily

• Low fat, high fruit/vegetable diet

Local Built environment changes

• Food related

• Physical activity related

Why?

Improved health status

Lower medical costs - public and private

A more productive workforce

A more competitive local economy

A healthy community

1. Childhood obesity prevalence has _______________ over three decades.

a. Doubledb. Tripledc. Stayed the samed. None of the above

Post Test Questions

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2. Childhood obesity is associated with which of the following:

a. Hypertensionb. Type 2 diabetes mellitusc. Otitis media

Post Test Questions

3. Treatment of childhood obesity should include:

a. cardiac catheterizationb. healthy lifestyle counselingc. renal ultrasound

Post Test Questions

4. Which of the following is included in the 5/2/1/0 messaging:

a. 5 servings of fruits and vegetables daily b. limit TV or computer time to 2 hours or less daily c. participate in 1 hour or more of play or physical activity

daily d. drink zero sweetened drinks every daye. all of the above

Post Test Questions