Obesity affects almost 38% of U.S. adults, according to the CDC’s National Health and Nutrition Examination Survey. Here’s how plans and providers can create positive change.
Obesity affects almost 38% of U.S. adults, according to the CDC’s National Health and Nutrition Examination Survey, and is a major cause of heart disease, type 2 diabetes, and up to 20% of adult cancers.
Despite common thought, however, the primary determinant of health and disease is not genetics, but rather lifestyle and environment. “Scientific evidence is growing that what we eat, how we move, and how we think are the foundations of good health and a long and productive life-not to mention the root cause of 75% of disease, premature death, and healthcare costs,” says Michael Parkinson, MD, MPH, FACPM, senior medical director, Health and Productivity, University of Pittsburgh Medical Center (UPMC) Health Plan and WorkPartners, Pittsburgh, Pennsylvania. “Obesity is a risk factor for multiple diseases, affecting different end-organs and contributing to a diminished quality of life and excessive medical care. Healthcare executives need to acknowledge, address and adopt a ‘root cause’ approach to the business of healthcare.”
Here’s a look at 10 things plans and providers can do to help combat the obesity epidemic.
Focusing on better nutrition and increased physical activity are among the most impactful efforts healthcare organizations can make. For every $1 invested in nutritional education, there is a $10 reduction in healthcare costs, according to the American Public Health Association.
“Because physicians have been trained in the ‘medical model’ as opposed to a ‘healthy living model,’ most doctors underemphasize healthy eating, physical activity, and stress reduction in their approach to treating predominantly lifestyle-caused conditions such diabetes and heart disease,” Parkinson says. “Yet they have been shown to be the greatest influence and most trusted agent in healthcare. Increasing awareness among healthcare professionals about the efficacy of ‘lifestyle medicine’ to prevent, treat, and even reverse disease will be increasingly important in improving health and reducing obesity.”
Efforts need to be integrated within an organization, adds Marna Canterbury, MS, RD, director, Community Health, HealthPartners, Minneapolis, Minnesota. HealthPartners makes it a priority to promote better eating in multiple ways. For example, its primary care clinics have partnered with local grocers to offer a “fruit and veggie prescription,” including a $10 off coupon for fresh fruits and vegetables. It also partners with employers to promote good nutrition and physical activity.
Payers should provide coverage for services that help to address obesity, including coverage for adults to get counseling, according to recommendations by the United States Preventive Services Task Force. They should also provide coverage for bariatric surgery and FDA-approved drugs for the management of being overweight or obese, according to the 2013 recommendations for management of overweight and obesity in adults published in Circulation. “They should also support accommodations for people with obesity, such as appropriate-sized blood pressure cuffs, gowns, and chairs,” says William Dietz, MD, PhD, chair and director, Sumner M. Redstone Global Center for Prevention and Wellness, Milken Institute School of Public Health, The George Washington University, Washington D.C. He cites significant stigma and bias surrounding obesity-both inside and outside of the clinical setting.
Research has found that due to bias, providers spend less time with obese patients in appointments, devote less time to discussions, assign more negative stereotypes such as being lazy, and provide fewer intervention strategies. Patients with obesity are less likely to get preventive health services and exams, including cancer screenings, pelvic exams, and mammograms. “Weight bias leads to worse outcomes for patients with obesity,” says Dietz.
Obese patients are also more likely to delay or cancel appointments, according to research.
The Stop Obesity Alliance tool, “Why Weight? A Guide to Discussing Obesity & Health With Your Patients,” can help clinicians better understand obesity and how to discuss weight with patients in a respectful, productive way.
Weight and lifestyle problems start at home. It’s critical to consider the entire family when developing programs and resources to support healthy lifestyles and choices. “Historically, the focus has been on specially prescribed diets and exercise for overweight children or for a single family member, while the rest of the family continues their old habits,” says Christine Sexton, MS, RN, director, Care4U Program and Interventions, CareSource managed care plan, Dayton, Ohio. “Long-term success comes when you engage the entire family in healthy meals and make physical activity a priority for everyone. Starting healthy practices at a young age should also be a priority.” CDC research found that one in eight U.S. preschoolers is obese, and children who are obese are five times as likely to be overweight or obese as adults.
CareSource partnered with a large health system to conduct a pilot program to specifically address childhood obesity. When creating initiatives to fight childhood obesity, it uses a model that encourages the entire family to engage in meal planning and physical activities, while limiting screen time. A study published in Appetite showed that parents are the best role models for their children when it comes to setting the stage for a lifetime of healthy choices.
CareSource offers members interactive tools, including a digital population health tool that members engage with for inspiration, education, goal setting, and tracking of weight and weight loss, Sexton says. In one state, it introduced a mobile app for children and their parents that packages nutrition and physical activity education as a game with coaching and goals. In its initial pilot of the app, 80% of child participants experienced weight loss, with an average weight loss of eight to 10 pounds.
CareSource recognizes that members often face barriers that prevent them from making healthier choices, so it tries to remove those barriers, Sexton says. One example is its fitness program for its dual-eligible (Medicaid and Medicare) member population.
These members get coverage for gym memberships, and those with mobility challenges receive kits with supplies and instructions for doing at-home exercises. According to the U.S. Department of Agriculture, a common challenge for members is the engrained cultural belief that eating healthy is always more expensive and less convenient. To combat this, CareSource partnered with large regional grocery chains to offer members personal shopping trips with certified dietitians, where they are shown affordable healthy choices available at their local grocery store.
Encourage members to use the prevention benefits offered as part of their healthcare coverage. “Understanding their benefits can help them maintain or improve their health through services available to them at little to no cost,” says Kandi Lannen, RD, director, Wellness, Priority Health, Grand Rapids, Michigan. “Using preventative offerings will identify problems early on, potentially minimizing time away from work.”
All of Priority Health’s plans cover preventative services in some capacity. By visiting a physician regularly, members can better track health changes, such as a slow increase in blood pressure or weight gain. A member may not notice subtle changes, but a physician may view it as a trigger of a potential chronic disease, such as obesity. “It is important to take the time now to prevent what could be costly and significant issues later,” says Lannen.
Outpatient nutrition consulting is another benefit to explore. “This is a great way for members to use their health insurance coverage to combat obesity, and also improve their overall health,” Lannen says. “These consulting visits can assist a member with finding a healthy eating plan that meets their unique health needs.”
A health plan might also cover massage therapy or chiropractic care. These alternative therapies are increasing in popularly because they offer a more natural form of medicine. “Both can assist with keeping muscles balanced and in shape to become active or to stay active and avoid the obesity epidemic,” Lannen says.
Prevention is an underused tool in the fight against obesity and other chronic disease, and payers should invest in developing these efforts, say experts. Dietz advises working with employers to institute evidence-based workplace wellness programs. Research suggests that such programs can improve behaviors-including increasing physical activity, improving diet, and quitting smoking-and also improve clinical measures such as blood pressure and cholesterol. A 2016 article in Journal of Occupational and Environmental Medicine noted that while the literature on a “culture of health” in the workplace and financial outcomes is still emerging, evidence shows that such workplaces have employees who are more likely to take care of their health and that medical costs are lower at workplaces that rate highly on both leadership support and program implementation.
As the U.S. healthcare system moves toward fully implementing a value-based system of care, it could incentivize payers to reward prevention directed at obesity and the diseases that result from it. “The move to value-based care should have payers thinking of Benjamin Franklin’s adage, ‘An ounce of prevention is worth a pound of cure,’” says Dietz. “It’s ever more essential to shift the approach, incorporating and promoting evidence-based prevention programs.” An example is the YMCA’s Diabetes Prevention Program (DPP), which was shown to reduce healthcare costs and prevent diabetes. This prompted the U.S. Department of Health and Human Services to recently propose expanding coverage of DPP in Medicare. Federal officials said DPP saved $2,650 per Medicare patient in the program over 15 months. It also significantly reduced the risk of those participants developing diabetes, as average weight loss was approximately 5% of body weight. “This is value-based care at work in the real world,” says Dietz.
Reversing trends in obesity requires a long-term commitment to working with multiple community partners to create community-level change, Canterbury says. Healthcare organizations can serve as trusted leaders in convening a coalition to create an environment that encourages healthy eating and physical activity in a community.
Partnerships are necessary to change norms about food choices and physical activity, Canterbury continues. HealthPartners’ PowerUp initiative began in 2012 by convening advisors among businesses, schools, healthcare providers, community and civic leaders, families, the religious community, and public health organizations.
PowerUp makes better eating and physical activity easy, fun, and popular by designing activities that kids will enjoy. “The initiative is a call to action to do what’s best for kids and create a community where they grow up healthy,” Canterbury says. “A strong communications strategy engages the community through advertising, newsletters sent home with students, a website, social media presence, and Chomp-a popular giant carrot mascot.”
The 2010 White House Task Force on Childhood Obesity concluded that limited access to healthy choices can lead to poor diets and higher levels of obesity and other diet-related diseases. “This means that hunger and obesity go hand in hand,” Sexton says. The CareSource Foundation partners with food banks in some of the communities it serves to provide thousands of pounds of food to the community. It also supports community gardens and playground initiatives to ensure that more children have safe places for physical activity. According to the CDC, half of the children in the United States do not have a park, community center, and sidewalk in their neighborhood.
Health plans should promote the integration of available treatments to maximize outcomes. This includes integration within specialties-such as combining counseling with medications, which has been shown to result in additive and sometimes synergistic benefits, and also among specialties-such as integrating clinical obesity treatment with ongoing community support. “Aim for coordinated, integrated care that attacks the problem at its multiple roots, finds synergies, and leverages different expertise and knowledge bases,” says Scott Kahan, MD, MPH, director, National Center for Weight and Wellness, and medical director, Strategies to Overcome and Prevent (STOP) Obesity Alliance, George Washington University, both in Washington D.C. “A particular facet of this is to combat the tendency to pit prevention against treatment; some argue that we should focus our resources on prevention; others on treatment. This is a dogmatic fight between two sides of the same coin. Prevention and intervention are both essential, and support one other. Prevention-related interventions, alone, will not typically help those who are already affected; treatment alone will not help those without obesity. But they interact.”
For example, prevention strategies that increase access to healthful foods, alone, won’t likely result in much weight loss, if any, in a patient with significant obesity. But in the context of ongoing counseling and obesity treatment, having access to healthy foods will support their weight loss behaviors and improve risk factors.
Healthcare organizations should institute an evaluation framework to measure the impact of initiatives over time, including changes in behaviors, attitudes, and awareness in the community. Along with more traditional health and economic metrics, measures can include well-being, healthy communities, and individual and community engagement. Novel data sources include the community health needs assessments required of hospitals and county health rankings.
Health outcomes can take years to observe in a community setting, so evaluative methods should include measuring short, medium, and long-term changes in the community. “Changes in institutional practices are important to measure because they may precede and drive policy change,” Canterbury says. For example, changes in the food/physical activity environment at a school can influence change on a policy level by demonstrating the positive effects to decision makers.
In addition to data, stories of change can also be a key measure. For example, HealthPartners uses the story of a couple who benefited from the Valley Outreach Food Shelf. The couple had a limited income and used the food shelf to help make ends meet. They were able to choose more fruits and vegetables and within several weeks, the change in diet gave them more energy to get out and walk more. In a few months, the husband’s blood pressure decreased from 200/100 to 160/80.
Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.