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


1
Community Solutions to the Challenges of
Childhood Obesity November 4, 2005 Its easier
to build a child than fix an adult. Eduardo J.
Sanchez, M.D., MPH Commissioner, Texas Department
of State Health Services
2
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

3
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

4
I. The Whole Person Context Sound Mind, Sound
Body
5
Three Guiding Principles
  • Sound Mind, Sound Body
  • Prevention first, treatment if necessary
  • Partnership

6
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

7
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

8
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

9
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

10
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

11
Adverse Childhood Experiences Smoking
12
Adverse Childhood Experiences Attempted Suicide
13
Adverse Childhood Experiences Intravenous Drug
Use
14
Adverse Childhood Experiences
Death
Early Death
Disease, Disability, and Social Problems
Adoption of Health-risk Behaviors
Social, Emotional, Cognitive Impairment
Adverse Childhood Experiences
Birth
15
II. The Education Context What you dont know
can kill you.
16
Texas High School Graduation Rate 2002 - 2003
Source Texas Educations Agency AEIS Report
17
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
18
Leisure Time Physical Activity (Texas), By
Education Level, 2002-2003
Percent
19
Prevalence of Obesity by Education
Source American Journal of Preventative
Medicine, 200427 (3S)
20
Health Literacy
  • Most medical information on internet written
    at 12th grade level
  • Average American reads at 8th-9th grade level
  • Average Medicaid recipient reads at 5th grade
    level

21
III. The Economic Context Are we getting our
moneys worth?
22
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.
23
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
24
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
25
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.
26
IV. The Conceptual Context Are we going to
redefine health care to include medical care and
public health?
27
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.
28
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).
29
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
30
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
31
V. The Obesity Challenge Is it really that
serious?
32
Obesity Trends Among U.S. Adults
1996
2004
No Data lt10 1014
1519 2024 25
BRFSS, 1991, 1996, 2004
33
2005 Texas is 6th Most Obese State each 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,
34
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

35
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
36
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
37
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.
38
The Cost of Overweight and Obesity in Texas,
2010-2040
39
Three Disturbing Trends
Obesity and Diabetes CDC NHANES
Expenditures CMS, Health 2004
40
Texans with Diagnosed Diabetes 1994 - 2004
41
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
42
  • 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
43
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
44
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.
45
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

March 2005 Annals of Internal Medicine Vol.
142 5
46
VI. Getting off the critical list Some good
efforts are already underway
47
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

48
Pediatric Obesity A Clinical Toolkit for
Healthcare Providers
  • Diagnosis Overview
  • Treatment Overview
  • Practitioners Tools
  • Patient Handouts

49
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
50
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

51
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

52
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

53
Prescription for Better Health Turn 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

54
Cost of Comprehensive 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

55
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

56
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
57
5 Simple Rules
  • Eat smart
  • Be active
  • Sleep plenty
  • Dont smoke
  • Stay connected
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