Originally Published August, 2004

 

Today, public policy experts are scrambling to address the obesity dilemma. According to data from the National Center for Health Statistics at the Centers for Disease Control and Prevention, 30% of U.S. adults (more than 60 million people) aged twenty years or older are obese. (The Center for Consumer Freedom, a nonprofit coalition of restaurants, food companies, and consumers, disputes the accuracy of the numbers.) Despite the disagreement, few can quibble over the fact that Americans are getting fatter each year, and the resulting health concerns, from diabetes to heart disease, are driving up healthcare costs for public and private insurers and for the employers who provide insurance.

In a study titled “The Impact of Obesity on Rising Medical Spending,” published in the medical journal Health Affairs, Kenneth E. Thorpe and co-authors Curtis S. Florence, David H. Howard, and Peter Joski, estimate that “the proportion of and spending on obese people relative to people of normal weight account for 27 percent of the rise in inflation-adjusted per capita healthcare spending between 1987 and 2001.” They also estimate that “increases in obesity prevalence alone account for 12 percent of the growth in health spending.” (Interestingly, the Institute of Medicine of the National Academies estimates that, after adjusting for inflation and converting to 2004 dollars, U.S. healthcare expenditures related to obesity and being overweight range from $98 billion to $129 billion annually.)

According to Thorpe, a Woodruff professor and department chair for health policy and management at Emory University’s Rollins School of Public Health, little research exists on the link between obesity and the rise in healthcare costs, the impact on employers, and health insurers. “Consultants and economists focus on the cost of treatment, but few focus on the rise of disease itself. These are modifiable factors. Unfortunately, controlling obesity has never been a part of the discussion as a strategy for controlling healthcare spending.”

Dr. Jeffrey P. Koplan, vice president for academic health affairs at the Woodruff Health Sciences Center of Emory University, adds that instead of just focusing on the ailments associated with obesity, medical practitioners need to shift their thinking from treatment to prevention. He prescribes a multifaceted approach to deal with obesity, with government agencies, schools, worksites, and community groups encouraging individuals to adopt a healthier lifestyle. (Koplan chairs the Institute of Medicine of the National Academies Committee on the Prevention of Childhood Obesity.)

Thorpe agrees with Dr. Koplan’s contention, noting that clinicians need to “focus their intellectual energy on finding ways to change behavior. Most of all, business has an incentive to take action through on-the-job health programs. Look at the condition of those now coming into the labor market. They’re coming in with a whole host of medical problems, from pulmonary disease to hypertension, and more. There seems to be a disconnect—with employers not understanding how the disease prevalence links to their healthcare insurance costs and lost days on the job.”

Changes in the nature of work could be contributing to the lack of employer response on the obesity problem. Dr. Kimberly Rask, director of the Emory Center on Health Outcomes and Quality, says that in the past, a company might employ an individual for the entirety of their employment history. “They might have a close relationship with the person, and they might have been able to see a payoff in dealing with a chronic problem over time. There is such tremendous turnover at work now that employers may feel they have no responsibility for this kind of thing. In turn, we have no one accountable for realizing the prevention investment. If you’re a publicly traded company, and your investment dollars are limited, frankly, Wall Street doesn’t reward you for kicking money into an employee health program. As well, dealing with an employee on the obesity problem becomes complicated, since it also may involve someone’s self image. Employers have to avoid stigmatizing their employees or resorting to punitive actions.”

Still, says Dr. Rask, employers need to move away from shortsighted policies. Says Dr. Rask, “We know that obese employees are more likely to have diseases that lead to more time off. We need to show employers that obesity, even at its early manifestations, hits the bottom line. There’s nothing yet done, public policy-wise, but we can inform employers directly about this. The employee incentives need to be structured correctly.” She adds that as people become more aware of the health consequences of obesity and seek medical treatment, revisions in healthcare will be needed to encourage individuals to seek routine care. Treating the earlier manifestations of obesity is much cheaper than the chronic conditions that result from long-term obesity. Dr. Rask asks, “Are people receiving regular healthcare? Are they seeing their physician at least once a year for routine physicals and counseling? Larger deductibles and co-pays affect patient behavior and make them less likely to see a physician.”

The confounding nature of the obesity problem also makes it difficult to resolve. Chip Frame, executive director of the Center for Healthcare Leadership at Emory University, says that obesity has a “multitude of causes, making it one of the more difficult social issues to handle.” (Frame is also a professor of marketing at Emory University’s Goizueta Business School.) “This isn’t a clear cut issue such as smoking, where you can say that tobacco is bad for you. People need to eat. There are a variety of processed food companies, fast food restaurants, others in the hospitality business, and a ton of food marketers, who are noting that if you use their products or eat their food judiciously, that there isn’t a problem.”

Of course, says Frame, healthcare providers are taught to be the patient’s advocate. They sit on the “other side of the fence,” opposing the fast food establishments and the makers of all the chewy and gooey treats. “What we’ll see is a back and forth warfare,” predicts Frame. “Regulation will have to be through the free market, as more Americans, pushed on by failing health, will become more aware and committed to staying away from processed food or fast food.” He views a change in attitude as the biggest stumbling block, and the best route for success, in curbing the obesity problem.

For now, businesses are responding to the ever-increasing demands of the obese patient as medical consumer. Healthcare institutions and medical technology providers are working to deal with the special circumstances that obesity creates. Clinicians note a marked rise in treatment for stroke, hypertension, heart disease and arthritis. On the tech side, older types of CAT scans and MRI machines may not work for the morbidly obese patient. Nancy Gillen, vice president of the magnetic resonance division at Siemens Medical Solutions, a supplier of healthcare technology and equipment, says, “Access to healthcare is needed for everyone. And, for us, when we design medical technology, patient comfort becomes our number one concern. So, we have to think of the obese patient, as well.”

In the past, Gillen says that the strength on MRI machines wouldn’t facilitate a good image on an obese patient. As well, morbidly obese people weren’t always able to fit into some of the older equipment. Siemens Medical Solutions now makes a variety of its diagnostic machinery to accommodate a more diverse patient population, including the Magnetom Espree, an open bore MRI with high-field power that can accommodate a much larger individual. Says Gillen, “Everyone deserves access to good quality medical care. That needs to be the concern, before anything else.”

Part of that quality mandate, says Dr. Rask, must be focused toward preventative care. She believes a needed shift in thinking must come from the clinicians and the public, who may not necessarily view this as the public policy issue that it is. “We could look back to what happened with smoking, and there were many who saw it as a lifestyle choice, even when we knew smoking was unhealthy. It took a long time to get it to be a public health issue. So, now we’re beginning to get awareness on obesity. The key is educating a new generation—encouraging healthy lifestyles in children. Families and schools should take a big role in this.” 

There are some encouraging signs that the American public is beginning to rethink the way that they eat. Frame says to think back a decade ago, and remember the state of the fast food industry then. “Who could have imagined that McDonald’s would be selling salads and fresh fruit offerings today?” He also cites the popularization of organic food chains, such as Whole Foods and Wild Oats. These large organic and natural food supermarket chains are distant relatives of the small and dingy natural food coops of the past.

But, says Jagdish Sheth, a Charles H. Kellstadt professor of marketing at Emory University’s Goizueta Business School, a more dramatic shift in American lifestyle requires a rethinking of the way people live and work today. He notes, “We’ve moved from an agricultural society to an industrial one, and finally to the information age, and along the way, the level of physical labor has decreased dramatically.” Developers often build homes far from access to public transport, requiring people to hop into their cars to access a store or a train. There are fewer and fewer sidewalks. Large garages and driveways dominate the suburban landscape, beckoning to the more sedentary two-to-three car family. Interestingly, a National Institutes of Health initiative called “Obesity and the Built Environment,” started in 2004, is studying “city and regional planning, housing, transportation, media, access to healthy foods and availability of public and green spaces (such as playgrounds, walking paths, etc.) as determinants of physical activity and nutritious dietary practices.”

Considering the hectic pace at home and work, many more Americans are finding little available time for an exercise routine or for cooking a nutritious meal, adds Sheth. He cites statistics that estimate one and one-half meals of each day are now eaten from sources other than the home. Unfortunately, our food intake and calorie count has probably increased because of prepared foods.” Sheth doubts individuals will make the needed changes in lifestyle until cutbacks on health insurance require it. “Considering the escalating costs, government might have no choice but to accept changes to employer health plans at some point. Co-pays may go 50/50 in the next ten to fifteen years, as they have for dental care. Twenty years down the road, employers may have the right to exclude some pre-existing conditions under their employee medical insurance plans—possibly chronic conditions such as hypertension or diabetes. Then, people will understand the need to be careful of what they eat. This will finally put pressure on individuals to alter their lifestyle.”