Community Solutions to the Challenges of Childhood Obesity November 4, 2005 Its easier to build a ch

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Community Solutions to the Challenges of
Childhood Obesity November 4, 2005Its easier
to build a child than fix an adult.Eduardo J.
Sanchez, M.D., MPHCommissioner, Texas Department
of State Health Services
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Environmental Perspectives 1

• An aging population with increasing medical care
  costs
• An increasing Hispanic population
• An epidemic of obesity
• An explosion of type 2 diabetes
• A significant of Texans with mental illness
  and/or substance abuse conditions

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Environmental Perspectives 2

• A shortage of healthcare providers
• Wide, in some cases, growing health disparities
• The challenge of improving health literacy
• The highest of residents without health
  insurance
• Compelling reminders Texas must be prepared for
  natural and man-made disasters

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I. The Whole Person Context Sound Mind, Sound
Body
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Three Guiding Principles

• Sound Mind, Sound Body
• Prevention first, treatment if necessary
• Partnership

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Adverse Childhood Experiences (ACE) Study

• In the mid-1980s Kaiser Permanente conducted an
  obesity program
• In trying to understand the programs high
  dropout rate, they conducted detailed life
  interviews of almost 300 individuals
• Researchers discovered that sexual abuse was
  common among dropouts, that abuse always
  predated obesity

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Adverse Childhood Experiences (ACE) Study

• As a follow-up, Kaiser Permanente CDC conducted
  ACE study
• Study involved 19,000 mostly middle class, middle
  aged adults
• Results show childhood abuse household
  dysfunction led to chronic diseases decades later
• Traditionally viewed as public health problems,
  behaviors may also be coping mechanisms

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Adverse Childhood Experiences

• Child Abuse or Neglect
• Physical abuse
• Sexual abuse
• Abandonment

• Trauma in Childs
• Household
• Substance Abuse
• Parental divorce
• Mentally ill or suicidal household member
• Violence to mother
• Imprisoned household member

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Adverse Childhood Experiences

• Effects of Trauma
• Difficulty controlling anger
• Hallucinations
• Depression
• Panic reactions
• Anxiety

• Health Risk Behaviors
• Smoking
• Obesity
• Suicide
• Alcoholism
• Drug abuse
• Sexually transmitted disease
• Self-injury
• Eating disorders

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Adverse Childhood Experiences Long-Term
Consequences

• Disease and Disability
• Heart disease
• Cancer
• Chronic lung disease
• Emphysema
• HIV/AIDS
• Mood disorders
• Anxiety disorders

• Social Problems
• Homeless
• Prostitution
• Delinquency, violence and criminal behavior
• Re-victimizations rape domestic violence
• Un-Employment
• Inter-generational transmission of abuse

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Adverse Childhood Experiences Smoking
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Adverse Childhood Experiences Attempted Suicide
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Adverse Childhood Experiences Intravenous Drug
Use
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Adverse Childhood Experiences
Death
Early Death
Disease, Disability, and Social Problems
Adoption of Health-risk Behaviors
Social, Emotional, Cognitive Impairment
Adverse Childhood Experiences
Birth
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II. The Education Context What you dont know
can kill you.
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Texas High School Graduation Rate2002 - 2003
Source Texas Educations Agency AEIS Report
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Education The Greatest Predictor of Longevity

• The overall death rate for people 25- 64 with
  less than 12 years education is more than twice
  that for people with 13 or more years of
  education.
• Less than 12 years of education 615.6 deaths per
  100,000
• 13 or more years of education 207.9 deaths per
  100,000
• The lower the education level, the greater the
  likelihood that individuals will engage in
  unhealthy behaviors.

CDC National Center for Health Statistics, Vital
Statistics Vol. 53, 5, Deaths, 2002
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Leisure Time Physical Activity (Texas), By
Education Level, 2002-2003
Percent
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Prevalence of Obesity by Education
Source American Journal of Preventative
Medicine, 200427 (3S)
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Health Literacy

• Most medical information on internet written
  at12th grade level
• Average American reads at 8th-9th grade level
• Average Medicaid recipient reads at 5th grade
  level

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III. The Economic Context Are we getting our
moneys worth?
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Growth in National Health Expenditures 19802011
from 1,000 to 9,000
6000 (2004)
Per Capita Costs
Levit et al. Health Affairs 200221172181.
Projection from Heffler et al. Health
Affairs 200221207218.
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The Rising Spiral of Health-Care Costs

• Healthcare premiums are growing more than 3 times
  faster than workers wages and 2.5 times faster
  than the inflation rate
• Percentage of employers providing health benefits
• 2000 69
• 2005 60
• Healthcare cost increases (national)
• 2005 9.2
• 2004 11.2
• 2003 13.9

2005 Kaiser Foundation Survey
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The Rising Spiral of Health-Care Costs

• State of Texas employee health care costs up 53
  since 2000
• Health care now consumes 30 of total state
  budgets
• Medicaid alone accounts for 20

National Governor's Association Center for Best
Practices
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The Price is Not Right

• The U.S. Ranks
• Health Care Spending 1st
• Life Expectancy 28th
• U.S. 1.79 Trillion

Source The World Health Report 2003, Total
Population at Birth.
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IV. The Conceptual Context Are we going to
redefine health care to include medical care and
public health?
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Causes of Death in United States 2002
Actual Causes of Death2
Leading Causes of Death1
Tobacco
Heart Disease
Poor diet/lack of exercise3
Cancer
Alcohol
Stroke
Infectious agents
Chronic lower respiratory disease
112,000
Pollutants/toxins
Unintentional Injuries
Firearms
Diabetes
Sexual behavior
Pneumonia/influenza
Motor vehicles
Alzheimers disease
Illicit drug use
Kidney Disease
Percentage (of all deaths)
Percentage (of all deaths)
Sources 1 National Vital Statistics Reports,
Vol. 53, No. 15, February 28, 2005. 2 Adapted
from McGinnis Foege, updated by Mokdad et. al.,
2000. 3 JAMA, April 20, 2005Vol 293, No. 15, pg
1861.
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Increased Life Expectancy
Increased years due to public health measures 25
Increased years due to medical care advances 5
Source Centers for Disease Control and
Prevention (CDC).
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The Healthcare Equation is Out of Balance

• Supply
• Increasing Access
• Improving Quality of Care
• Improving Technology
• Improving Meds
• Improving Workforce

• Demand
• Older
• Heavier
• More Sedentary
• Un Underinsured
• Health Illiterate

Demand Reduction Is Imperative
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The Healthcare Equation is Out of Balance

• Supply
• Increasing Access
• Improving Quality of Care
• Improving Technology
• Improving Meds
• Improving Workforce

Health Promotion
Demand Reduction Is Imperative
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V. The Obesity Challenge Is it really that
serious?
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Obesity Trends Among U.S. Adults
1996
2004
No Data lt10 1014
1519 2024 25
BRFSS, 1991, 1996, 2004
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2005 Texas is 6th Most Obese Stateeach state
more than 25 obese

• Mississippi
• Alabama
• West Virginia
• Louisiana
• Tennessee
• Texas, Kentucky, Michigan

How Obesity Policies are Failing in American
Trust for Americas Health August 2005,
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Preventing Childhood Obesity- Health in the
Balance

• Despite steady progress over most of the past
  century toward ensuring the health of our
  countrys children, we begin the 21st Century
  with a startling setbackan epidemic of childhood
  obesity.
• - Institute of Medicine

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Prevalence of At Risk and Overweight in Texas
Children, 2001
At risk of overweight is gt85th but lt95th
Percentile for BMI by Age/Sex Overweight is gt
95th Percentile for BMI by Age/Sex
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Causes of Overweight/Obesity

• Too many calories in too few calories burned
• 1977-1993 Average daily food intake increases
  by almost 200 calories
• 1960 McDonalds serving of Fries 200 calories
• 2000 McDonalds serving of Fries 610 calories

New England Journal of Medicine, 5/22/03 review
of Fat Land by Greg Critser
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Overweight and Obesity-Pediatric Conditions
Affecting Children

• Type 2 Diabetes Mellitus
• High Blood Pressure
• High Cholesterol
• Gallbladder Disease
• Sleep apnea
• Behavioral Health Problems

Source Overweight and Obesity Health
Consequences. National Center for Chronic Disease
Prevention and Health Promotion.
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The Cost of Overweight and Obesity in Texas,
2010-2040
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Three Disturbing Trends
Obesity and Diabetes CDC NHANES
Expenditures CMS, Health 2004
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Texans with Diagnosed Diabetes1994 - 2004
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Who Will Develop Diabetes?

• 1/3 of American children
• 2/5 of blacks Hispanics
• 1/2 of Hispanic females

CDC.gov/nccdphp/aag/aag_ddt.htm
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• Diabetes Almost 1 of every 5 spent on health
  care in the U.S. is for a person with diabetes

Source Diabetes Care, Volume 26, Number 3,
March 2003, p926
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Cost of Diabetes in Texas

• 1.5 million Texans with diabetes
• 13,240 Annual medical costs with diabetes
• 5,640 Age-adjusted average annual per
  person costs without diabetes
• 7,600 Added cost due to diabetes per person
• 11.4 billion Added cost to treat 1.5m Texans
• with diabetes

Diabetes Care, Volume 26, Number 3, March 2003
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Projected Diagnosed Diabetes in the U.S.
Projected number of people with diagnosed
diabetes (millions)
Population growth assumption
Projected
High
Middle
Low
Reported
U.S. Census Bureau, National Health Interview
Survey (NHIS), CDC, NCHS. Boyle et al. Diabetes
Care, Vol. 24, No.11, November 2001.
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Diabetes Prevention ProgramLifestyle
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

March 2005 Annals of Internal Medicine Vol.
142 5
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VI. Getting off the critical list Some good
efforts are already underway
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AAP Overweight Obesity

• Prevalence in pediatric populations has reached
  epidemic proportions
• Prevention is critical
• Early recognition of excessive weight gain should
  be routine
• Families should be educated to recognize the
  influence they have on childrens health habits
• Dietary habits should be fostered that encourage
  moderation
• Regular physical activity should be consciously
  promoted

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Pediatric Obesity A Clinical Toolkit for
Healthcare Providers

• Diagnosis Overview
• Treatment Overview
• Practitioners Tools
• Patient Handouts

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Policy Strategic Plan for the Prevention of
Obesity in Texas

• 4 Goals for Obesity Prevention
• Awareness
• Mobilizing families, schools, and communities
• Promote policies and environmental changes
• Monitor obesity rates and related behaviors

http//www.tdh.state.tx.us/phn/obesity2Dplan.pdf
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State Initiatives re Obesity

• Dept. of Ag Nutrition Policy/vending machines
• Legislative mandates to authorize physical
  activity through 8th grade
• Mandatory requirement to have a School Health
  Advisory Council (SHAC) in every school district
• Re-establishment of statewide SHAC

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Non-governmental Initiatives re Obesity

• Marathon Kids
• A free endurance building running/walking
  nutrition program for kindergartners though 5th
  graders
• children and their families run/walk 26.2 miles
  over a period of 6 months, at school and at home,
  in increments of ¼ mile at a time, until their
  Final Mile Medal Celebration
• 80,000 Texas children have participated so far

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DSHS Obesity-Related Initiatives Partnerships

• TAFP CME Kaiser Permanente video
• Worksite wellness initiative with Building
  Healthy Families Coalition
• Texas Strategic Health Partnership
• SHAC video with Commissioners Combs Neely
• Community Skill-Building Trainings for promoting
  nutrition and physical activity

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Prescription for Better HealthTurn Information
Into Action

• Eating right staying physically active are
  essential to good physical mental health
• Increased physical activity improved nutrition
  for kids
• At home, physically active recreation
• At school (Coordinated School Health Programs)
• Increased physical activity improved nutrition
  for adults
• At home, model behavior
• At work, worksite wellness
• Schools impact communities, not just kids

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Cost ofComprehensive School Health Programs

• 4,258 Texas Public Elementary Schools
• 2,500 Average Cost for Coordinated School Health
• 4258
• x 2500
• 10,645,000
• 1 prevented cases of diabetes/year per school
  32 million

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What Happens When Schools Take Action to Make a
Difference?

• Improved academic performance
• Higher self-esteem for students
• Lower absentee rates
• Fewer behavioral problems
• Higher school morale
• Behaviors, values knowledge that can sustain a
  healthy life for our children

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Washoe County ISD in Nevada (6,600 employees)
spent 1 million on gastric bypass surgeries
25,000 surgery x 1,000,000 25 Billion
morbidly obese Texans
On average, 2002 health-care costs for an obese
person were 1,244 higher than for a person with
a healthy weight
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5 Simple Rules

• Eat smart
• Be active
• Sleep plenty
• Dont smoke
• Stay connected