Perspectives

Weighty Debate

Health Experts Seek Common Ground in Fight Against Obesity

Two-thirds of all Americans are now overweight or obese, a public health crisis blamed on everything from the omnipresence of high-caloric foods to the breakdown of personal responsibility. At a recent symposium held at RAND’s Pittsburgh office, three health experts debated the causes of the trend and what could be done about it. Their perspectives differed regarding the causes, but they agreed that the solutions need to involve everyone: government, the health care system, the food industry, employers, and, yes, individuals themselves.

Our Environment, Ourselves

Deborah Cohen, an obesity researcher at RAND, attributed the rise in obesity to our surroundings. The inability to manage one’s weight cannot be attributed to personal failing or lack of willpower, she said. Rather, the human brain is wired to respond to visual food cues — things like ads, fast food icons, and food itself — by craving food. Moreover, our surroundings have undergone a transformation over the past 20 years, with an explosion of these cues. “I even see chocolate being sold in the lingerie department!”

These changes, coupled with our brain wiring, she argued, conspire to prevent us from managing our weight. She also pointed to the larger portions served at restaurants and the surging consumption of sugary beverages, such as sodas and sports drinks.

Weight management is a matter of balancing caloric intake (food) and caloric output (exercise), but Cohen said the environment is also thwarting our ability to exercise: Many inner city areas lack parks and other recreational facilities; high crime rates make many parents fearful of allowing their children to play outdoors; and suburbs are often designed to discourage walking.

Childhood obesity is “everyone’s problem and everyone’s responsibility.”

Health Insurance Incentives

As obesity spreads, health care costs rise for chronic health conditions like Type II diabetes, heart disease, and osteoarthritis. With mounting trepidation, employers who provide health insurance have asked their health insurance companies what they intend to do about it. Donald Fischer, senior vice president for integrated clinical services at Highmark Blue Cross Blue Shield in Pittsburgh, said that if the trend continues, health care and insurance costs will increase at faster rates.

Fischer began by echoing Cohen. “It’s not uncommon to find kids who are drinking more than a thousand calories a day in juices, sodas, and sports drinks,” he said, noting that schools have a perverse incentive to maintain soft drink vending machines, because the proceeds from sales and sponsorships subsidize extracurricular activities.

But he also cited factors that interfere with the clinical treatment of overweight or obese patients. Parents of overweight children rarely see their children as being overweight, he said. If a physician raises the issue, parents tend to view it as simply a cosmetic one, failing to comprehend the health consequences.

For their part, physicians say they lack the knowledge to diagnose and effectively treat obesity. Perhaps more to the point, their schedules allow little or no time for counseling patients about weight loss: Because obesity has not traditionally been classified as a disease, physicians receive no reimbursement for their time spent treating it.

JENNIFER NIELSEN  Gathering for a conversation at the RAND Pittsburgh office are Donald Fischer, senior vice president for integrated clinical services at Highmark Blue Cross Blue Shield in Pittsburgh; Philip Hallen (moderator), chairman of the Pittsburgh History & Landmarks Foundation and chairman emeritus of the Pennsylvania Humanities Council; Deborah Cohen, a RAND behavioral scientist; and Stephen Thomas, director of the Center for Minority Health and the Philip Hallen Professor of Community Health at the University of Pittsburgh Medical Center.

In response, Highmark has made several key policy changes. The insurance company has redefined obesity as a diagnosable disease and now reimburses for its treatment, based on the recommendation by the American Academy of Pediatrics (AAP) that overweight children need to be treated medically. Highmark has also assembled an obesity toolkit for physicians. This toolkit includes a small device for determining a child’s body mass index, a measure of body weight relative to height; a chart showing the health risks associated with increasing body mass; and a copy of the AAP treatment guidelines.

Fischer emphasized that childhood obesity is “everyone’s problem and everyone’s responsibility. While the health care system plays a vital role, we can’t put all the responsibility on it. Instead, we need to continue to work hand-in-hand with employers, health care providers, municipal parks and recreation departments, and others.”

It Takes a Community

Stephen Thomas, who is director of the Center for Minority Health and the Philip Hallen Professor of Community Health at the University of Pittsburgh Medical Center, turned the audience’s attention to the fact that blacks and Latinos are far more likely to be obese than are whites. “Many in the minority community are poor,” he said, “and I can buy a coke for 50 cents, but a bottle of water costs a dollar.”

He described an innovative University of Pittsburgh program designed to prevent obesity. Called the Healthy Black Family Project, the program has enrolled about 6,000 people, educating them to make healthy changes in their lives. The program is housed in the inner city, rather than on the university campus, to be close to the community it serves.

“We need to actually go into neighborhoods to appreciate both the opportunities and the challenges. It’s not enough for a physician to say you need to lose weight; it must be balanced by what you actually do when you leave the doctor’s office. This project, which takes the results of all the studies and puts the findings into practice, is giving real people the help they need to take charge of their weight.”

Thomas emphasized the far-reaching effects of the obesity epidemic, citing the results of a recent nationwide health survey that found California to be the 6th healthiest state in the nation but Pennsylvania to be only 45th. “Corporations are not going to want to open factories in places with so many unhealthy people, so good health is an investment in economic growth!”

Fischer left the audience with a note of promise. He pointed to improved school lunches and to society’s shift in attitudes toward smoking over the past 10 to 20 years as evidence that people can change their behavior, even deeply ingrained behavior.

“No one gets fat on purpose,” Cohen reassured the audience. “No one can rely on willpower alone against the food environment.”

One audience member observed that the mass media “advertise all these fattening foods, but they could be helping inform people about the consequences of their choices.” Another said that physicians should communicate to parents in terms they understand. A food services manager added, “To make better choices, consumers need information at the point of purchase.”

Thomas summed up the general mood. “We need to resist shifting responsibility,” he said, “and stay on point, continue to innovate, and cross-collaborate.”