James A Vohs Award:
A Focus on Obesity, Part 1:
••Spring 2003/Vol. 7, No. 2

Health Systems

A conversation with the Care Management Institute Board of Directors and William Dietz, MD, PhD
Approaches to the Epidemic of Weight Management and Obesity | pdf >>

By William Dietz, MD, PhD

Editor's Note: Through a series of working meetings, the Centers for Disease Control and Prevention (CDC) and the Care Management Institute (CMI) have brought together leading experts from academia, medicine, health care delivery systems, research, and the federal government to assess and promote implementation of programs for managing overweight and obesity. William Dietz, MD, PhD, has been an active leader of this collaboration.

As the disease burden in the United States has shifted from acute infectious diseases to chronic diseases, public health officials, the medical community, and health policymakers have begun to focus on those nonacute problems that account for a substantial proportion of morbidity and mortality in this country. Increasingly, obesity and overweight have taken the spotlight as one of the nation's most rapidly growing and, from the public health perspective, deeply troubling health problems.¹

Both adult and pediatric obesity are areas of tremendous concern.

Obesity in adults is defined as a body mass index wt[kg]/ht[m²] (BMI) of 30 or more.² Prevalence data from the CDC's current National Health and Nutrition Examination Survey (NHANES)³ show that 30% of American adults fall into that category--a proportion that is increasing annually.⁴ Even more alarming is the fact that growth in prevalence of severe obesity--in adults with a BMI of 40 or above--is far outstripping even the growth rate for simple obesity.⁵ The number of American adults classified as severely obese has tripled in the past 15 years, and 15% of African-American women have a BMI of 40 or more.³

People who have a BMI of 40 or higher are a priority population for weight control. The only way to address severe obesity for many such patients is gastric bypass surgery. The collaboration between Kaiser Permanente (KP) and the CDC was prompted by recognition that to address this problem effectively, we need to do so well before people reach a BMI of 40. Moreover, when 30% of the population has a problem, effective care becomes a public health issue, and effective care for obese patients is what has driven our interest in this collaboration.

Additional research suggests that prevalence of pediatric obesity is increasing even more rapidly than prevalence of adult obesity.⁶ Data from nationally representative surveys show that childhood (ages 6-11 years) overweight has doubled between 1980 and 1999^6,7 and that adolescent overweight, affecting youth from ages 12 to 17 years, tripled during the same period.^6,7 Fifteen percent of children and adolescents are overweight,⁷ and persistence of childhood overweight into adulthood may account for the rapid increases currently seen in class 3 obesity (represented by a BMI of 40 or more). Data from longitudinal studies suggest that children with onset of overweight before eight years of age who become obese adults have an average BMI of more than 40.⁸ Children and adolescents represent another priority population.

The question that originally brought the CDC and KP together was "What practical, effective, nonsurgical approaches should exist or should be considered for prevention and treatment of overweight patients and obesity in medical settings?"

• Practical--What can we do now without waiting for a new body of research?
• Effective--In many cases, we have efficacy but not effectiveness.
• Nonsurgical--KP has surgical options for obesity in almost all of its regions, and we didn't want to exclude surgery. However, if people reach the stage at which obesity can only be treated surgically, we have not done an effective job of treating people earlier or of preventing obesity.

Although the initial query emphasized the medical setting, the KP/CDC working group participants recognized that an approach limited to medical settings was not likely to be effective without reinforcing what is done there with strategies in the community, workplace, and home. This approach requires expanded partnerships among health care providers, communities, schools, and nongovernmental organizations as well as community, state, and national government agencies--especially health care providers and payers at these levels.

No state Medicaid program reimburses for routine care of obesity. The opportunity now exists to begin a dialog in a number of states where the obesity problem is growing. Obesity may begin to drive coverage of preventive health services through Medicaid, because it's so clearly an issue of "pay now [for prevention] or pay later [for disease]." In addition, Tommy Thompson, Secretary of Health and Human Services is very supportive of preventive strategies. Through a national health perspective, we can begin to emphasize lack of physical activity and poor nutrition as risk factors for obesity, analogous to tobacco use for lung disease, and all that implies for community, state, and federal policies and restructuring the public health and disease care system.

1991

1995

1999

2001

Obesity trends among US adults--1985-2001, full survey data available at: www.cdc.gov/nccdphp/dnpa/obesity/trend/index.htm BRFSS = Behavioral Risk Factor Surveillance System

What is needed to identify practical, effective, nonsurgical approaches to obesity and overweight treatment and prevention? One key means of finding solutions is more and better applied research. We must invest in alternative approaches, such as improved nutrition and physical activity. Recent trials, such as the Diabetes Prevention Program,⁹ demonstrate the promise of those strategies if we can convert them to practical strategies that can be applied in primary care.

The CDC's Guide for Community Preventive Services¹⁰ offers several evidence-based strategies that can be used in health care, worksite, and community settings. Two new strategies are scheduled to be added to the physical activity chapter on the relationship of community structure to physical activity and obesity prevention. Applied research on the natural history of obesity in African-American women is desperately needed. When does it start, and how does it differ from what we know about this disease in white and other populations? Clearly, differences exist in how this disease manifests and how people think about it.

What about drug-based treatments? Although some promising drugs for treatment of obesity have emerged,¹¹ I believe that reliance on drugs for obesity control will be prohibitively expensive. I calculated what it would cost to provide everybody in the United States who had a BMI of 30 or more with one of the two currently approved medications for obesity for one year. These costs are equivalent to the direct costs of obesity.

The United States also lacks an effective dietary strategy for combating obesity. Despite substantial changes in the American diet, such as increased consumption of fast foods and soft drinks, as well as inflation of portion size,^12,13 we do not yet have a sufficient body of evidence to justify targeting any one of these factors.

A far more basic question revolves around whether the public actually understands not only that obesity is a health risk but, more simply, precisely what obesity is. Existing survey data suggest that people do not believe that obesity is a health risk--it's much more commonly perceived as a cosmetic problem. Most people think that "obesity" may apply to a person with a BMI of 40 or 50, not 30. A very important challenge remains in understanding what kind of language we should use to talk about this issue.

Finally, what policy and environmental changes need to be made so that healthy choices in nutrition and physical activity become easy choices? Infectious diseases were successfully controlled in the last century because of policies such as assured water potability. What are the elements of policy or environmental change that need to be adopted to address this problem effectively for the next 100 years? Successful approaches to obesity will also be successful approaches to diabetes, cardiovascular disease, and cancer. Obesity is one of the drivers of chronic disease, but we now have a chance to change the approach to chronic diseases in a way that was not possible in the past.

The formation of partnerships of all kinds will continue to be a critical element in effective treatment and prevention of obesity and overweight. Already expressing concerns about the issue and actively seeking solutions are the United States Department of Health and Human Services; several state governments; medical societies, such as the American Dietetic Association and the American Academy of Pediatrics; research sponsors, such as the Robert Wood Johnson Foundation; major employers, such as General Motors; public service organizations, such as the YMCA; health care associations, such as the American Heart Association and the American Cancer Society; and a host of schools, community groups, and other organizations. Although the opportunity clearly exists to build a very broad coalition around this issue, several crucial strategic decisions must be made, such as whether these partnerships should be formed at the national, state, or local level.

The opportunity exists to engage a wide coalition of partners in this effort, and not the least of these partners in terms of importance and stature is KP. The initiative really needs to come from the health care arena.

KP is ideally suited to take a leadership role in participating in and fostering these activities. KP has the authority needed to discuss the health care impact of obesity and overweight management and to bring others to the table to discuss this issue. Since our initial telephone conference 12 months ago, the energy and progress generated by the partnership between the CDC and KP has been extraordinary. But a medical shift alone will not be sufficient to address this problem. The opportunity is for broader partnerships and alliances that will help to take this issue forward.

References

1. Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH. The disease burden associated with overweight and obesity. JAMA 1999 Oct 27;282(16):1523-9.
2. National Heart, Lung, and Blood Institute. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report. Washington (DC): National Institutes of Health; 1998. (NIH Publication No. 98-4083) Available from: www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.htm (accessed March 13, 2003).
3. Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among US adults, 1999-2000. JAMA 2002 Oct 9;288(14):1723-7.
4. Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA 2003 Jan 1;289(1):76-9.
5. Freedman DS, Khan LK, Serdula MK, Galuska DA, Dietz WH. Trends and correlates of class 3 obesity in the United States from 1990 through 2000. JAMA 2002 Oct 9;288(14):1758-61.
6. Troiano RP, Flegal KM. Overweight children and adolescents: description, epidemiology, and demographics. Pediatrics 1998 Mar;101(3 Pt 2):497504.
7. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents, 1999-2000. JAMA 2002 Oct 9;288(14):1728-32.
8. Freedman DS, Khan LK, Dietz WH, Srinivasan SR, Berenson GS. Relationship of childhood obesity to coronary heart disease risk factors in adulthood; the Bogalusa Heart Study. Pediatrics 2001 Sep;108(3):712-8.
9. The Diabetes Prevention Program. Design and methods for a clinical trial in the prevention of type 2 diabetes. Diabetes Care 1999 Apr;22(4):623-34.
10. Increasing physical activity. A report on recommendations of the Task Force on Community Preventive Services. MMWR Recomm Rep 2001 Oct 26;50(RR18):114.
11. Yanovski SZ, Yanovski JA. Drug therapy: obesity. N Engl J Med 2002 Feb 21;346(8):591-602.
12. Nielsen SJ, Popkin BM. Patterns and trends in food portion sizes, 1977-1998. JAMA 2003 Jan 22-29;289(4):450-3.
13. Young LR, Nestle M. Expanding portion sizes in the US marketplace: implications for nutrition counseling. J Am Diet Assoc 2003 Feb;103(2):231-4.

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