V. Key Issues: Population Health >> E. Health Promotion >> Obesity (last updated 11.1.15)
- 1 Key Questions (by Gabriela Vargas and Gabriela de la Llana)
- 1.1 What Are the Social Costs of Obesity?
- 1.2 What Sorts of Legislation Have Congress Passed That Would Promote the Reduction of Overweight and Obesity? What is Occurring at Both the State and Federal Level?
- 1.3 Where Are We Headed? What Do Future Policies Imply for Both General and Specific Health Care Coverage for Overweight and Obese patients?
- 1.4 What Is the Prevalence of Obesity? Should Obesity Really Be a High Priority in the Face of Other Health Disparities?
- 1.5 What Benefit Can We Reap By Targeting Childhood Obesity As the Key to Preventing the Worsening of an Overweight and Obesity Epidemic?
- 1.6 What is the size of the obesity problem?
- 1.7 What is the nature of the obesity problem?
- 1.8 What current policies address obesity?
- 1.9 What is the impact of current policy?
- 1.10 How can policy be improved?
- 2 Analysis
- 3 Resources
Key Questions (by Gabriela Vargas and Gabriela de la Llana)
In order to understand the obesity problem in the United States, it is essential to first to put a face to the abstract concept of obesity. It is not surprising to note that obesity not only affects adults but equally children. According to a 2001-2002 study, 30.6% of adults were obese, 5.1% were extremely obese, and 31.5% of children aged-6-19 were at risk for obesity and overweight (Hedley et al, 2004). Although obesity is high for all demographic groups, results indicate that there are continuing disparities between the sexes and racial and ethic groups (Hedley et al, 2004). Not only does obesity affect individuals but it also affects society as whole. Obesity is an important risk factor that may increase the incidence and severity of associated diseases like heart disease and diabetes. For example, obese individuals are 2 times more likely to have hypertension and three times more likely to have type II diabetes mellitus than non-obese individuals (Thompson et al, 1999). This in turn means deteriorating health for the American population and extra costs associated with increased consumption of medical care (Miljkoviv, 2006). According to the Center for Disease Control and Prevention, 9.1% of total U.S medical expenditures, which may be as high as $78.5 billion, in 1998 were medical expenses attributed to overweight and obesity (CDC). State-level costs range from $87 million in Wyoming to $7.7 billion in California (Finkelstein et. al, 2004). These rising costs indicate that the United States government should intervene to alleviate the social costs that ultimately are carried by the American citizens.
What Sorts of Legislation Have Congress Passed That Would Promote the Reduction of Overweight and Obesity? What is Occurring at Both the State and Federal Level?
With the increasing serving portions at fast-food chains and the rise of obesity, both the federal and state governments are becoming more active in their response to this concern. Results from lawsuits against fast-food chains such as Pelman vs. McDonalds Corp. are shaping U.S policy with respect to regulation in food distribution (Mello et al, 2003). State governments are executing new nutritional and physical activity programs (CDC). And local governments are making use of zoning laws to regulate the number of fast food chains in a particular area (Fernandez, NYTimes). Moreover, the federal, state, and local governments are working together to improve the health environment in local schools by requiring food vendors to schools to distribute only snacks that meet RDA recommendations and requiring schools to promote a school health program. It is with this concerted effort that obesity could be fought at all fronts and thus provide a healthier environment for future generations.
Where Are We Headed? What Do Future Policies Imply for Both General and Specific Health Care Coverage for Overweight and Obese patients?
Private health insurance spending on illnesses related to obesity has increased more than tenfold since 1987, according to Nanci Hellmick of USA Today. Overall, employers and privately insured families spent $36.5 billion on obesity-linked illnesses in 2002, up from an inflation-adjusted $3.6 billion in 1987. That’s up from 2% of total health care spending on obesity in 1987 to 11.6% in 2002, according to USA Today. On average, treating an obese person cost $1,244 more in 2002 than treating a healthy-weight person did. About 31% of U.S. adults are obese — 30 or more pounds over a healthy weight. That’s up from 23% in the late 1980s and 15% in the late 1970s. The study comes as businesses, the government and consumers are struggling with soaring health care costs. Costs that are predicted to rise exponentially include health care spending, medical conditions and trips to the doctor, hospital and pharmacy.
Currently, Medicaid does not cover obesity, though under Medicare, hospital and physician services to treat obesity are excluded unless the treatment is for certain co-existing conditions. Typically, the condition is considered on a case-to-case basis, which only contributes to the tremendous health care costs. Given the high prevalence of obesity among women and poorly educated populations–both of which contribute largely to the obese population—, it could be presumed that many current Medicaid recipients are likely to have obesity. Surgery for the treatment of obesity, a widely accepted “treatment” for obesity is covered on a limited basis. According to the Medicare Coverage Manual, gastric bypass surgery, which is a variation of the gastrojejunostomy, is performed for patients with extreme obesity, and will be covered if it is medically appropriate for the individual to have such surgery. The number of surgical procedures for weight loss has been rising as rapidly as the overweight and obesity epidemic, which United States Health officials have stated consists of a minimum of 30% of the US adult population alone. According to Dr. Carolyn M. Clancy, director of the Agency for Healthcare Research and Quality, obesity surgery has helped thousands of Americans lose weight and reduce the risk of diabetes and other life-threatening chronic diseases that are commonly associated with prolonged obesity. However, she does indicate that it is important for patients to consider the potential complications, of which there are plenty. In an article by Robert Pear of the New York Times, the federal government reported that four out of every ten patients that undergo weight loss surgery (such as gastric-bypass) develop complications within six months. Federal researchers found that these complications increased health care costs substantially. According to William E. Encinosa, an economist at the health research agency, medical spending averaged $29,921 for obesity surgery and six months of follow-up care. For patients who experienced complications, spending averaged $36,542. And for those with complications that required readmission to a hospital, the average was $65,031. Because the costs are up because so many more Americans are obese, they are being more aggressively treated for weight-related illness, and the problem is only going to get worse unless different policies are implemented. If more cost-efficient strategies are not employed, then the US government faces outrunning its health care spending capacity, leading to incredible economic debt in the long run.
What Is the Prevalence of Obesity? Should Obesity Really Be a High Priority in the Face of Other Health Disparities?
Results of the National Health and Nutrition Examination Survey for 1999–2002 indicate that an estimated 16 percent of children and adolescents ages 6–19 years are overweight. For children, overweight is defined as a body mass index (BMI) at or above the 95th percentile of the CDC growth charts for age and gender. According to the National Center for Health Statistics (NHANES), the 1999-2002 findings for children and adolescents suggest the likelihood of another generation of overweight adults who may be at risk for subsequent overweight and obesity related health conditions. According to the Surgeon General, this is an incredible health care concern; this implies that, despite that it is not the leading cause of death in the United States currently, overweight and obesity rates have been increasing so exponentially in the past decade alone that it is predicted to be the primary cause of premature death within the next ten years—even before tobacco. Thus, policies aimed at reducing overweight and obesity would indeed be a high priority. In the words of the Surgeon General, “the primary concern of overweight and obesity is one of health and not appearance.” This is because obesity has a high risk of premature death—an estimated 300,000 deaths per year may be attributable to obesity; the risk of death rises with increasing weight. Even moderate weight excess (10 to 20 pounds for a person of average height) increases the risk of death, particularly among adults aged 30 to 64 years. Individuals who are obese (BMI > 30)* have a 50 to 100% increased risk of premature death from all causes, compared to individuals with a healthy weight. The majority of these deaths are due to chronic disease, which induces tremendous economic and policy-oriented costs. Obesity is a primary contributor to heart disease, a leading chronic disease in the United States. The incidence of heart disease (heart attack, congestive heart failure, sudden cardiac death, angina or chest pain, and abnormal heart rhythm) is increased in persons who are overweight or obese (BMI > 25). High blood pressure is twice as common in adults who are obese than in those who are at a healthy weight. Obesity is also associated with elevated triglycerides (blood fat) and decreased HDL cholesterol (“good cholesterol”). Type 2 diabetes is commonly found among obese patients, where even a weight gain of 11 to 18 pounds increases a person’s risk of developing this disease; over 80% of people with diabetes are overweight or obese. Overweight and obesity are associated with an increased risk for some types of cancer including endometrial (cancer of the lining of the uterus), colon, gall bladder, prostate, kidney, and postmenopausal breast cancer. Women gaining more than 20 pounds from age 18 to midlife double their risk of postmenopausal breast cancer, compared to women whose weight remains stable. Sleep apnea (interrupted breathing while sleeping) is more common in obese persons, and obesity is associated with a higher prevalence of asthma. For every 2-pound increase in weight, the risk of developing arthritis is increased by 9 to 13%; several studies have shown that symptoms of arthritis can improve with weight loss. Additional health consequences include that overweight and obesity are associated with increased risks of gall bladder disease, incontinence, increased surgical risk, and depression. Because it is such an incapacitating disease, obesity can affect the quality of life through limited mobility and decreased physical endurance as well as through social, academic, and job discrimination.
What Benefit Can We Reap By Targeting Childhood Obesity As the Key to Preventing the Worsening of an Overweight and Obesity Epidemic?
Obesity is affecting the United States in epidemic proportions. It has shown a dramatic increase in the past 20 years. According to Overweight and Obesity Trends: US Obesity Trends 1985-2005, in 1985 only a few states showed obesity prevalence rates between 10-14%; in 2005, however, only 4 states had obesity prevalence rates less than 20% and about 17 states had rates greater than 25%. This alarming rise in obesity has caused concern because obesity is an important risk factor that may increase the incidence and severity of associated disorders like diabetes, hypertension, and heart disease. Together, these disorders are the leading cause of morbidity and premature mortality.
Even more unsettling, about 15% of U.S children aged 6-11 were considered obese, according to a 1999-2002 report from Center for Disease Control and Prevention (CDC). Today, 15% of youths are classified as being overweight, and another 15% are grouped as being at risk for becoming overweight. These overwhelming statistics have led many to believe that by targeting American youth in the fight against obesity could be a key to its prevention. Because children spend a substantial amount of time in school, it has been argued that public schools should have a responsibility to teach children about the importance of good nutrition, regular physical activity, and health consciousness. Recently, prodded by U.S policy, a new trend toward eliminating nutritionally-poor foods and promoting exercise has taken hold that might result in the reduction of obesity in school-aged youth. School-based nutrition, physical education, and after-school activity programs could play a major role in reducing the sedentary behavior of American youth. These school-based obesity interventions can be divided into primary and secondary prevention. Primary prevention focuses on the prevention of the onset of obesity and targets every student, while secondary prevention targets only overweight youth.
What is the size of the obesity problem?
- Health burden
- Economic Burden
- Public Spending
- Severe Obesity In Adults Cost State Medicaid Programs Nearly $8 Billion In 2013. “Overall, severe obesity cost state Medicaid programs almost $8 billion a year, ranging from $5 million in Wyoming to $1.3 billion in California. These costs are likely to increase following Medicaid expansion and enhanced coverage of weight loss therapies in the form of nutrition consultation, drug therapy, and bariatric surgery. Ensuring and expanding Medicaid-eligible populations’ access to cost-effective treatment for severe obesity should be part of each state’s strategy to mitigate rising obesity-related health care costs.” (Health Affairs, November 2015)
- Public Spending
What is the nature of the obesity problem?
- Individual determinants
- Social determinants
What current policies address obesity?
- Federal policies
- State policies
- Local policies
- Community policies
- School-based policies
- College-based policies
- Worksite policies
- Clinical health policies
What is the impact of current policy?
- Net effectiveness
How can policy be improved?
- Federal policies
- State policies
- Local policies
- Community policies
- School-based policies
- College-based policies
- Worksite policies
- Clinical health policies
- Congressional Budget Office. Estimating the Effects of Federal Policies Targeting Obesity: Challenges and Research Needs. The share of the U.S. population that is obese has increased substantially since 1980, posing a significant public health challenge. Because obesity is associated with numerous diseases and higher average health care spending, lawmakers have expressed interest in developing policies that would reduce the prevalence of obesity. Determining the likely effects of such policy proposals is difficult, however. Despite a rapidly growing body of literature that explores the effects of obesity on health and health care spending, research on the effects that policy interventions aimed at weight loss would have on the federal budget is largely lacking. The Congressional Budget Office has determined that the available evidence does not support the conclusion that certain policies to stem obesity—discussed in more detail below—would generate significant savings for the federal government. (A bibliography detailing the studies and related scholarly literature that CBO has consulted for its analysis is available on CBO’s website.) Given the limitations of current research, some of which are outlined in this blog post, further well-designed studies and systematic reviews of the literature on the effects of obesity interventions and their budgetary consequences would enhance CBO’s analytic capabilities in this area and could change the agency’s conclusions.
- Trust for America’s Health. F as in Fat: How Obesity Threatens America’s Future. August, 2013. The latest annual report from the Robert Wood Johnson Foundation (RWJF) and Trust for America’s Health (TFAH) shows that adult obesity rates remained level in every state except for one, Arkansas. Thirteen states now have adult obesity rates above 30 percent, 41 states have rates of at least 25 percent, and every state is above 20 percent, according to the report.
- Fat of the Land: The Obesity Epidemic (Michael Fumento, Viking, 1997)
- Abdel-Hamid, T. K. (2009). Thinking in circles about obesity: Applying systems thinking to weight management. New York: Springer.
- Abdel-Hamid, T., Ankel, F., Battle-Fisher, M., Gibson, B., Gonzalez-Parra, G., Jalali, M., Kaipainen, K., Kalupahana, N., Karanfil, O., Marathe, A., Martinson, B., McKelvey, K., Sarbadhikari, S. N., Pintauro, S., Poucheret, P., Pronk , N., Qian, Y., Sazonov, E., Oorschot, K. V., Venkitasubramanian, A. and Murphy, P. (2014). Public and health professionals’ misconceptions about the dynamics of body weight gain/loss. System Dynamics Review. 30: 58–76. doi: 10.1002/sdr.1517.
- National Obesity Comparison Tool (interactive state-level maps of U.S. showing county-level obesity rates)
- The Geography of Diabetes (interactive state-level maps of U.S. showing county-level diabetes rates; user can restrict results based on county poverty rate and obesity rate)
- Public Health Law Research. Obesity Prevention Laws. By utilizing a collaborative and iterative search process, researchers at the Harvard School of Public Health created this comprehensive database of obesity-related legislation enacted in the 50 states between 2000-2007. The dataset contains over 100 variables reflecting a diverse array of law ranging from restrictions on competitive foods in school to mandated diabetes screenings. This dataset was created with funding from the National Program Office for Public Health Law Research. For more details about the project, please see What public health law approaches help prevent obesity?
- Bridging the Gap. Soda and Fast Food Taxes. To improve understanding of soda and fast food taxes, Bridging the Gap researchers are providing data files coded for research analysis on taxes affecting these categories in each of the 50 states from 1997 to 2011. See these resources.
- Centers for Disease Control and Prevention. Prevent Diabetes
- Public Health Agency of Canada. Diabetes Health Information
Consumer Groups-Disease Associations
Policy Research Organizations
- Nutrition Obesity Research Centers (NORCS). NORCs are NIH-funded, university-wide research centers established to foster a multidisciplinary approach to basic, clinical, and translational research with an emphasis on understanding the metabolic factors, environmental influences, and associated genetic traits underlying nutrition and obesity-related health problems.
- University of Alabama at Birmingham Nutrition & Research Center
- University of Colorado Nutrition Obesity Research Center
- Harvard Clinical Nutrition Research Center
- University of Maryland Mid-Atlantic Nutrition Obesity Research Center
- University of North Carolina at Chapel Hill Nutrition Obesity Research Center
- Pennington Biomedical Research Center Nutrition Obesity Research Center
- University of Michigan Nutrition Obesity Research Center
- Washington University Nutrition Obesity Research Center
- Boston Nutrition Obesity Research Center
- Minnesota Obesity Research Center
- The New York Obesity Nutrition Research Center
- University of Washington Nutrition Obesity Research Center
- RAND Corporation. Obesity research.
- RAND Corporation. Childhood obesity.
- Rudd Center for Food Policy and Obesity, Yale University.
- Shape Up America. The purpose of Shape Up America! is to educate the public on the importance of the achievement and maintenance of a healthy body weight through the adoption of increased physical activity and healthy eating.
- Meridia. This site includes information for consumers on weight management by providing tips on eating and exercise. Sponsored by Knoll Pharmaceutical Company.
- Health Testing Centers. The Diabetes Fact Sheet
- What Diabetic Services Does Medicare Cover?
- Seniors with Diabetes – Take Control of Your Health