Food, Health, Hunger, and Obesity Texas United Methodist Women Legislative Summit January 24, 2010...

Food, Health, Hunger, and Obesity

Texas United Methodist Women Legislative SummitJanuary 24, 2010

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

Former, Texas Commissioner of Health

Five loaves and two fishes feed 5000

And Jesus, when he came out, saw much people, and was moved with compassion toward them… and he began to teach them many things. And when the day was now far spent, [he said to his disciples] Give ye them to eat. And they say unto him, Shall we go and buy two hundred pennyworth of bread, and give them to eat? He saith unto them, How many loaves have ye? ... And when they knew, they say, Five, and two fishes. And he commanded them to make all sit down by companies upon the green grass... And when he had taken the five loaves and the two fishes, he looked up to heaven, and blessed, and broke the loaves, and gave them to his disciples to set before them; and the two fishes divided he among them all. And they did all eat, and were filled. And they took up twelve baskets full of the fragments, and of the fishes. And they that did eat of the loaves were about five thousand men.

Matthew 25:35-40

I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in, I needed clothes and you clothed me, I was sick and you looked after me, I was in prison and you came to visit me.’

"Then the righteous will answer him, 'Lord, when did we see you hungry and feed you, or thirsty and give you something to drink? When did we see you a stranger and invite you in, or needing clothes and clothe you? When did we see you sick or in prison and go to visit you?’”

The King will reply, 'I tell you the truth, whatever you did for one of the least of these brothers of mine, you did for me.'

The Parable of the Good Samaritan

One day an expert in religious law stood up to test Jesus by asking him this question: “Teacher, what should I do to inherit eternal life?”

Jesus replied, “What does the law of Moses say? How do you read it?” The man answered, “‘You must love the Lord your God with all your heart, all your soul, all your strength, and all your mind.’ And, ‘Love your neighbor as yourself.’” “Right!” Jesus told him. “Do this and you will live!” The man wanted to justify his actions, so he asked Jesus, “And who is my neighbor?”


Jesus then replied with a story:

“A Jewish man was traveling on a trip from Jerusalem to Jericho, and he was attacked by bandits. They stripped him of his clothes, beat him up, and left him half dead beside the road. By chance a priest came along. But when he saw the man lying there, he crossed to the other side of the road and passed him by. A Temple assistant walked over and looked at him lying there, but he also passed by on the other side. Then a despised Samaritan came along, …


and when he saw the man, he felt compassion for him. Going over to him, the Samaritan soothed his wounds with olive oil and wine and bandaged them. Then he put the man on his own donkey and took him to an inn, where he took care of him. The next day he handed the innkeeper two silver coins, telling him, ‘Take care of this man. If his bill runs higher than this, I’ll pay you the next time I’m here.’ “Now which of these three would you say was a neighbor to the man who was attacked by bandits?” Jesus asked. The man replied, “The one who showed him mercy.” Then Jesus said, “Yes, now go and do the same.”

Food

US agricultural policies have contributed to the low cost of food, but not all food groups have been equally affected. • Compared to fresh fruits and vegetables, grains and oilseeds

are considerably cheaper than they were in previous decades. • This has changed corporate behavior and, subsequently,

consumer behavior.Effectively reducing the consumption of fast foods and other unhealthy options cannot be done without creating a level playing field for healthier food products. More information is needed on the relationships between crop prices, food prices, and US consumption patterns in order to ensure that agricultural policy helps make healthier food choices available and accessible to all.

Journal of Hunger & Environmental Nutrition, 4:3–19, 2009

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

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 sexesDeaths 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

rtal

ity

Rat

e

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.

Household Food Security in theUnited States, 2008

85% of American households were food secure in 2008—access at all times to enough food for an active, healthy life for all household members. 14.6 % were food insecure at least some time during the year, • including 5.7 % with very low food security—reduced food intake for one or more

household members was and disrupted eating patterns because the household lacked money and other resources for food.

Prevalence rates of food insecurity and very low food security • up from 11.1 % and 4.1 %, respectively, in 2007• the highest recorded since first survey conducted in 1995

The typical food-secure household spent 31% more on food than the typical food-insecure household. 55% of all food-insecure households participated in one or more of the three largest Federal food and nutrition assistance programs during the month prior to the 2008 survey.

Nord, Mark, Margaret Andrews, and Steven Carlson. Household FoodSecurity in the United States, 2008. ERR-83, U.S. Dept. of Agriculture,Econ. Res. Serv. November 2009.

Considering the Contribution of USAgricultural Policy to the Obesity Epidemic

1. Develop a vision of health in agriculture. “What would US agriculture and food system look like if public health were paramount?”2. Broaden public discussion around health and agricultural policy to include farmers, environmental groups, and other public interest organizations. 3. Investigate the relationships between crop prices, food prices, and food consumption. US agricultural policies have contributed to the low cost of food, but not all food groups have been equally affected. 4. Explore the relationship between commodity prices and corporate marketing. Corporate marketing has been targeted for promoting calorie-dense, sugar-laden foods. However, corporate marketing decisions are likely influenced by the profit potential of different foods.



5. Examine the drivers and goals of publicly funded agricultural research. 6. Develop a more nuanced discussion of commodity subsidies. In public debate around reforming agricultural policy through the 2008 Farm Bill, calls to reduce or eliminate federal subsidies to farmers became a key point of discussion. 7. Provide policy-makers with a broader environmental nutrition and prevention perspective on the economic costs of current agricultural policy.8. Explore the pros and cons of the USDA having authority over the federal nutrition and food assistance programs.


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%

“Persons who are naturallyvery fat are apt to die earlier than

those who are slender.”

– Hippocrates (400 B.C.)

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

The Impact of Obesity on Rising Medical Spending

27% of the rise in health care spending from 1987 to 2001 is 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 ($)

More Background

An estimated 75% of the cost of medical care is forchronic disease care

• Hypertension

• Diabetes

• Lipid abnormalities

• Cardiovascular disease

• Arthritis

CDC.gov

Controlling obesity is keyDallas Morning News Letter to the Editor, Jan 04, 2010 |

… health reform must include policies and strategies that work to improve the health of Americans and also prevent and reverse obesity.

Increasing obesity prevalence is associated with increasing heart disease, diabetes and some forms of cancer. And while death rates from cancer and heart disease have indeed decreased this past decade, the reduction is due more to better treatment than to less disease.

We must put in place what works to prevent and reverse obesity in the U.S. This will result in the prevention of heart disease, cancer and diabetes, reducing the demand for expensive, albeit effective, medical care and help to control health care costs.

Eduardo Sanchez, vice president and chief medical officer, Blue Cross and Blue Shield of Texas, Richardson

http://dallasmorningviewsblog.dallasnews.com/archives/2010/01/controlling-obe.html

mailto:[email protected]

Diabetes Prevention Program (DPP)

• a multi-center trial that examined the ability to prevent or delay the development of diabetes in a population withpre-diabetes

NEJM, 2002NEJM, 2002

Effect of Treatment on Incidence of Diabetes

Placebo Metformin Lifestyle

Incidence of diabetes 11.0% 7.8% 4.8%

(percent per year)

Reduction in incidence ---- 31% 58%

compared with placebo

Number needed to treat ---- 13.9 6.9

to prevent 1 case in 3 years

The DPP Research Group, NEJM 346:393-403, 2002

Diabetes Prevention Program:Lifestyle Modification vs. Metformin

• Compared with the placebo intervention, the lifestyle and metformin interventions both increased the quality-adjusted life years (QALY) by:

• $31,300 per QALY for metformin

•

• $1,100 per QALY for lifestyle interventions

• A quality-adjusted life year or QALY is a year of life adjusted for its quality. Saving one QALY through prevention is equivalent to extending a life for one year in perfect health

March 2005 Annals of Internal Medicine Vol. 142 #5

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

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

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.

Lessons Learned from tobacco control initiatives

Comprehensive approaches work best

Single interventions haven’t worked as well

Programs need to be sustained


1. Develop a vision of health in agriculture. “What would US agriculture and food system look like if public health were paramount?”2. Broaden public discussion around health and agricultural policy to include farmers, environmental groups, and other public interest organizations. 3. Investigate the relationships between crop prices, food prices, and food consumption. US agricultural policies have contributed to the low cost of food, but not all food groups have been equally affected. 4. Explore the relationship between commodity prices and corporate marketing. Corporate marketing has been targeted for promoting calorie-dense, sugar-laden foods. However, corporate marketing decisions are likely influenced by the profit potential of different foods.



5. Examine the drivers and goals of publicly funded agricultural research. 6. Develop a more nuanced discussion of commodity subsidies. In public debate around reforming agricultural policy through the 2008 Farm Bill, calls to reduce or eliminate federal subsidies to farmers became a key point of discussion. 7. Provide policy-makers with a broader environmental nutrition and prevention perspective on the economic costs of current agricultural policy.8. Explore the pros and cons of the USDA having authority over the federal nutrition and food assistance programs.


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 have received 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.

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

Criteria• Within the jurisdiction of local governments• Likely to affect children directly• Targeted to changing the food or physical activity

environments of children outside the school walls and the school day

• Actionable based on the experience of local governments or knowledgeable sources that work with local governments

• Where evidence is lacking or limited, have a logical connection with healthier eating or increased physical activity

Creating Healthy Environments

• Children and parents need healthy environments to make healthy choices

• Many children live in places where the unhealthy choice is the easy choice

Health Equity

• “Health equity is the fair distribution of health determinants, outcomes, and resources within and between segments of the population, regardless of social standing”1

• Many individuals do not have the resources or opportunities to eat more fruits and vegetables and be more physically active.

• Local governments can change people’s environments to provide equal access to factors that determine health

1CDC Health Equity Working Group

Recommendations

• Local context emphasized. Not “one-size-fits-all” recommendations

• Made final assessment of recommended action steps using a nominal voting procedure

• 15 strategies and 58 action steps in the report

• 12 most promising action steps highlighted

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

Meyers

breatk up by goals? spread out more?


• 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


• 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


• 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

"Healthy choices need to be the easy choices”.

– World Health Organization's Ottawa charter

Improving Diet & Physical Activity:Lessons Learned from TobaccoControl Campaigns

1. Address the issue of individual responsibility versus collective or environmental action early and often

2. Evidence of harm is necessary, but is not sufficient to motivate policy Undertaking research necessary to close the remaining knowledge gaps is therefore important to eliminate any persisting uncertainty, particularly with regard to the health effects of obesity.

3. Decisions to act need not wait for evidence of the effectiveness of interventions

4. Fully implement interventions known to be effective

5. The more comprehensive the package of measures considered, the greater the impact

Yach et al, BMJ 2005, 330 898-900


6. Broad based, well networked, vertical and horizontal coalitionsare key.

• Vertical coalitions include all levels of health services—from local health departments to regional and national authorities to WHO.

• It is increasingly clear that a wide array of players outside the traditional boundaries of health care need to be engaged and, often, encouraged to take the lead on certain aspects of the problem. But health workers still need to provide overall direction and leadership.

7. Change in support for tobacco control took decades of effort led by media savvy and politically astute leaders.

Yach et al, BMJ 2005, 330 898-900


8. Modest, well spent funds can have a massive impact, but without clear goals funding may not be.

• Ministries of finance and ministries of health alike need evidence for allocating scarce funds for preventive health interventions

9. Complacency that past actions will serve well in future may retard future progress.

• For diet, and especially obesity, there is still insufficient research of community based interventions to show best practices.

• Investment in large scale, community based research is needed to yield evidence of progress against obesity and other adverse outcomes of poor diet and physical inactivity.

Yach et al, BMJ 2005, 330 898-900


10. Complacency that past actions will serve well in future may retard future progress.

• For diet, and especially obesity, there is still insufficient research of community based interventions to show best practices.

• Investment in large scale, community based research is needed to yield evidence of progress against obesity and other adverse outcomes of poor diet and physical inactivity.

11. Rules of engagement with the tobacco and food industries need to be different and continually under review.

12. Risk factor envy is harmful—a joint approach is needed

• We need to build synergies rather than competition betweenthose active in tobacco control and those addressing diet andphysical activity.

Yach et al, BMJ 2005, 330 898-900

Improving Diet & Physical Activity:Lessons Learned from Tobacco Control Campaigns

We must help create the environments where healthy choices can be made by individuals and families and communities

Leadership and creativity are vital

Effective (evidence-based) interventions must be fully implemented

Evaluation of promising interventions is vital to build the evidence base

Comprehensive approaches are the most effective

Broad, networked coalitions are crucial

Change will take decades

Health promotion and disease prevention efforts must be collaborative, not competitive

We cannot demonize the food industry

Tackling Obesity and Hunger – start upstream

Sectors

• Health and Human Services

• Education

• Agriculture

Universal coordinated K-12 school health

• Universal breakfast and lunch

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

Steps to prevent and reverse childhood obesity and hunger

Universal coordinated school health programs

Toolkits for clinicians

Physician advocacy

Science based nutrition guidelines for all foods in schools

Classroom teaching about good eating

Fresh fruits and vegetables

Farm to School

School gardens

Steps to prevent and reverse childhood obesity and hunger

Universal school breakfast/lunch

30 minutes per day physical activity in schools

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 behind – 100% high school graduation

No child left inside

Why?

Improved health status

Lower medical costs - public and private

A more productive workforce

A more competitive local economy

A healthy community

Consistent with a Christian framework

Food, Health, Hunger, and Obesity Texas United Methodist Women Legislative Summit January 24, 2010...

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