Transcript Food, Health, Hunger, and Obesity

Food, Health, Hunger, and Obesity
Texas United Methodist Women Legislative Summit
January 24, 2010
Eduardo Sanchez , MD, MPH
VP 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?”
The Parable of the Good Samaritan
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, …
The Parable of the Good Samaritan
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
26.6%
Diseases of the heart
All cancers
22.8%
5.9%
Stroke
Chronic lower respiratory disease
5.3%
Unintentional injuries
4.8%
Diabetes mellitus
3.1%
Alzheimer’s disease
2.9%
Influenza and pneumonia
1.8%
Septicemia
1.4%
0%
Source: cdc.gov
9%
18%
27%
36%
The Preventable Causes of Death in the United States:
Comparative Risk Assessment of Dietary, Lifestyle, and
Metabolic Risk Factors (Danaei,2009)
Deaths attributable to individual risk (thousands) in both sexes
“Non-clinical factors affecting
mortality
Higher health literacy is correlated with lower mortality rates
50%
Mortality Rates by Health Literacy Levels
Definition: Levels of Health Literacy
39.4%
40%
20%
Adequate – understands most reading
tasks; misreads only complex
information.
Marginal – sometimes misreads
instructions and dosages and has
difficulty with complex information.
10%
Inadequate – often misreads Rx
instructions and appointment slips.
Mortality Rate
28.7%
30%
18.9%
0%
Inadequate
Marginal
Adequate
Literacy Level
Note: Based on 3,260 Medicare managed-care who were interviewed in 1997 to determine their demographic characteristics, chronic conditions, selfreported 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):1503-1509
Copyright © 2007 American Medical Association. All rights reserved.
Household Food Security in the
United 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 Food
Security in the United States, 2008. ERR-83, U.S. Dept. of Agriculture,
Econ. Res. Serv. November 2009.
Considering the Contribution of US
Agricultural 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.
Journal of Hunger & Environmental
Nutrition, 4:3–19, 2009
Considering the Contribution of US
Agricultural Policy to the Obesity Epidemic
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.
Journal of Hunger & Environmental
Nutrition, 4:3–19, 2009
Obesity Trends* Among U.S. Adults
BRFSS, 2007
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
Source: CDC Behavioral Risk Factor Surveillance System.
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2008
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
Source: CDC Behavioral Risk Factor Surveillance System.
25%–29%
≥30%
“Persons who are naturally
very 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)
YEAR
COST ($)
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
More Background
An estimated 75% of the cost of medical care is for
chronic disease care
• Hypertension
• Diabetes
• Lipid abnormalities
• Cardiovascular disease
• Arthritis
CDC.gov
Controlling obesity is key
Dallas 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
Diabetes Prevention Program (DPP)
• a multi-center trial that examined the ability to prevent or
delay the development of diabetes in a population with
pre-diabetes
NEJM, 2002
Effect of Treatment on Incidence of Diabetes
Placebo
Incidence of diabetes
11.0%
Metformin Lifestyle
7.8%
4.8%
----
31%
58%
----
13.9
6.9
(percent per year)
Reduction in incidence
compared with placebo
Number needed to treat
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
Prevalence of Childhood Obesity in the
United States
One in six children aged six to 19 are now considered overweight,
up from just one in 10 only 15 years ago
Percentage of Age Group
Population
Children and Adolescents
Considered Overweight by Age Group
20%
15.8% 16.0%
16%
12%
11.3%
17.6%
17.5% 17.0%
17.0%
2001-2004
2003-2006
10.5%
8%
4%
0%
1988-1994
1999-2002
Ages 6-11
Ages 12-19
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
IOM Comprehensive approach for preventing
and addressing childhood obesity
 Government
 Communities
 Public Health
Social Norms
and Values
 Worksites
 Health Care
 Health Care
 Agriculture
Sectors of
Influence
 Schools and
Child Care
 Education
 Media
 Home
 Land Use and
Transportation
Behavioral
Settings
 Demographic
Factors (e.g., age,
sex, SES,
race/ethnicity)
 Psychosocial
Factors
 GeneEnvironment
Interactions
 Communities
 Foundations
Individual
Factors
Food &
Beverage Intake
Energy Intake
 Industry
Food
Physical
Activity
Energy Expenditure
Beverage
Retail
Leisure and
Recreation
Entertainment
 Other Factors
Energy Balance
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
Considering the Contribution of US
Agricultural 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.
Journal of Hunger & Environmental
Nutrition, 4:3–19, 2009
Considering the Contribution of US
Agricultural Policy to the Obesity
Epidemic
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.
Journal of Hunger & Environmental
Nutrition, 4:3–19, 2009
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, type2 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-sizefits-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
12 Most Promising
Action Steps
• 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
12 Most Promising
Action Steps
• 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
12 Most Promising
Action Steps
• 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 Tobacco
Control 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
Improving Diet & Physical Activity:
Lessons Learned from Tobacco
Control Campaigns
6. Broad based, well networked, vertical and horizontal coalitions
are 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
Improving Diet & Physical Activity:
Lessons Learned from Tobacco
Control Campaigns
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
Improving Diet & Physical Activity:
Lessons Learned from Tobacco
Control Campaigns
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 between
those active in tobacco control and those addressing diet and
physical 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