Obesity and health-care reform: Public vs. private responsibility

Sep 21, 2010

Should obese patients receive public funding for medical treatment? Does health-care reform actually encourage the obese to gain weight? Should communities pass laws designed to help residents keep their weight in a healthy range?

Obesity policy consultant Morgan Downey, who publishes the Downey Obesity Report (www.downeyobesityreport.com), takes your questions about the relationship between the obesity epidemic and health-care reform, how public policy can encourage weight loss and more.

SPECIAL REPORT: Obesity in America

Since everyone has been paying for everyone else's healthcare for decades now through the constantly increasing insurance premiums that gave us an unsustainable Cadillac healthcare system, don't you think that all these intrusive steps taken to reduce the need for healthcare are just a smoke screen for the out of control healthcare bubble? Sure, you can reduce your cost of gasoline by never using your car, just like you can reduce your cost of healthcare by never needing it; but then why even have it?

We all need or will need health insurance. But most plans are geared to intervening late and poor coverage of chronic diseases. The new law tries to move in the direction of incentives to intervene earlier when outcomes are better and cheaper.

A week ago I was at a question and answer session with the superintendent of a major public school system, and when school lunches and nutrition came up, the focus was very clearly on the needs of special groups of kids -- peanut allergies, other allergies, halal or kosher requirements, whether or not to keep chocolate milk. Even this year, after all that has been in the news about childhood obesity and Michelle Obama's "let's move" program, he responded to the obesity issue that affects ALL children as "of course that's important too, and PE is a part of it also." No details beyond that. I understand from an admin standpoint that a child can die from an allergy and that parents of kids with any special requirement will be louder than the parent population as a whole, but this really made me despair. What more can be done to get at this problem at the school ages, when habits are really open to change? Is there legislation tied to Let's Move that has been passed, or is it hung up in one of the two houses? The general effort has had such bipartisan support (Mike Huckabee, etc.) that I thought now was the window for real change. I care deeply about this issue having had to lose 50 pounds a few years ago to get back to a healthy range. Only then did I realize how little I even knew about what to eat based on my previous "education."

Congress is working on an expanded school lunch bill to encourage better lunches. What I think what you are seeing is a reflection of how more parents are engaged on those specific items, while nutritional value of foods and PE is not something that typically a lot of parents push.

The "science" underpinning this entire discussion is incredibly flawed. The BMI in particular is so "one size fits all" as to be essentially useless. According to the BMI, most military servicemen (and probably all professional athletes) are overweight, and would be lumped in the "two thirds of all Americans" who are overweight or obese. For example, a 5' 11" man may weigh up to 196 pounds before the Navy even begins to consider whether a sailor is overweight. At that point, the Navy performs a body fat measurement to "ascertain if the sailor falls within the prescribed Navy Body Fat standards." Heres the problem: at that weight, the BMI indicates that the sailor is at least 17 pounds overweight and halfway to obese. According to the BMI, that sailor would need to lose 41 pounds [!] and weigh 155 pounds just to be in the middle of "normal weight." Indeed, were that sailor to lose 61 pounds and weigh 135 pounds, he would not be considered underweight by the BMI. At least the old Metropolitan Life Insurance height and weight tables acknowledged small, medium, and large frames. Sheesh!

The BMI is a great tool but mainly for population-level assessments. It has been shown to leave out a lot of people, especially women and some minorities, who may have BMI in the normal range but are metabolically obese. Other info, such as waist circumference, may be better to judge an individual's excess weight

I think our weight/fitness issues are a national disaster, but at the same time I think many people would not call someone who is only 30 or 40 pounds overweight "obese;" and also the BMI measurement used seems to me to over-hype the problem. Comments?

Clearly, as overweight/obese becomes more prevalent people get used to seeing more people overweight. But I think BMI may undercount many and overcount a few.

Is it true that the federal government subsidizes some crops which tend to be processed into food or food-ish substances that then require more government spending to deal with poor health? If so, couldn't we save money twice by cutting the subsidies?

Could not agree more. The problem is worse than you describe. The USDA has many programs passed by Congress, called "check-offs" which are designed precisely to increase human consumption of specific foods, like dairy (think cheese) meat, pork, even popcorn.

I suffer from headaches. I also enjoy hitting myself in the head with a brick, and some people have told me the two are related. But I think the right solution is for the government to buy me a helmet so I can continue my hobby without suffering the consequences. What do you think?

"Personal responsibility" has always been part of the equation. Problem is that only a few people can really control their weight. Weight is a function of personal behaviors, genetics and the environment. If you want to understand the interplay of these forces, see my site, www.downeyobesityreport.com

I do know that some obesity is not simply the result of poor eating habits and lack of exercise-- those people "can't" lose weight-- but isn't that a minority? Some portray being obese as a lifestyle choice, and try to use nice-sounding terms like "person of size" (as though others have no size). But it is a dangerous condition which DOES affect others, since it's driving up healthcare costs, resulting in higher insurance premiums, and costs to public hospitals, etc. Obesity is linked ot many diseases, from diabetes to inflammation of the intestine, and even cancer. Are we softpedaling the need for Americans to lose weight?

I think that there has been a lot of attention on the need no can deny to try to prevent obesity. Unfortunately, the results are not very encouraging. In fact over 60% of the country is overweight or obese. About half of adults are trying to lose weight at any one time. We need more tools to help those trying to lose weight.

I am tired of being told I am obese. Why is it anyone's business how much I weigh? I revel in high-fat food because it tastes better, and I cook with suet and lard. So why should anyone in government dictate to me that what I am doing is wrong. I don't look into their lives to criticize their food choices or what they are drinking. Why can't we be left alone?

I sympathize but the point the government and others are trying to make is that your actions are part of a larger picture. Many people are now entering Medicare, for example, with conditions caused by obesity. We will all be paying for their care. I do agree that the government and employers need to avoid being punitive with people who cannot control their weight and not blame individuals for condtions they have limited control over. On the other hand, you could probably replace the high fat foods with lower-calorie items. Better for you; better for all of us.

Have you estimated the future costs of obesity? We have now, and will have in the future, an explosion of Type 2 diabetes, the health (and financial) costs of which will be enormous. Of course, it is the portion sizes for the meals eaten out which are also enormous. I read one expert in the NYTimes who said that if he could do only one thing to change behavior, it would be that you could only eat what you had prepared. Do you agree?

I think the expert's advice is both right and naive. We don't live in a world where growing our own food and preparing it are convenient and low cost. Groups have estimated the costs (see my web site under Economics). Today the STOP Obesity Alliance is issuing a report on the additional costs individuals incur. See the  Washington Post website for more info.

Obesity is a physically uncomfortable condition for anyone. Most obese people also feel less attractive to others than if they were closer to normal weight. Paradoxically, as unpleasant as obesity is to endure, more and more people are becoming obese even though becoming obese happens only by repeated behavioral actions by the sufferer. If such a large segment of the population is engaging in self-harmful behavior, there must be many deep-running causes. That kind of problem is not going to be fixed by legislation.

Legislation can't fix it but it can help. We made an enormous investment in HIV/AIDS, as well as cancer and heart disease, all of which have behavioral aspects and continue to make progress. The same can happen for obesity.

As an obese person who is currently losing weight, I have been forced to change my opinion of what influence health-care reform will actually have on the obesity problem in this country. I fear that health-care reform will force doctors to promote the current conventional wisdom of low-fat diets with lots of processed "diet" foods. Well, I have years of experience gaining weight on these products. If we'd quit making things "healthy" by replacing the fat with sugar so foods can be promoted as low-fat, and if we'd quit adding sugar to otherwise healthy foods, like canned vegetables, and if the medical establishment actually provided obese people with solutions that work, we wouldn't have to worry so much about public funding and surgical treatments. Instead, my tax dollars are going to be wasted because so many of the people trying to lose weight are doing their best to eat what they are told are the better options,  and it's just making their problems worse.

Unfortunately, many physicians do not understand obesity and do not do a good job counseling patients on weigh managment. This can be fixed with better medical school and continuing medical education.

As someone who has recently lost a lot of weight by tracking what I ate, I became aware of how ignorant most of us are about how much we should eat each day, and how some innocuous sounding dishes, alone, can put you over your calorie budget for the day. I used an iPhone app set up a calolrie budget to track what I ate, and I know that there are other tools as well. Unfortunately, we all need to learn to pass on short term eating pleasure for a healthier life as we age. How do we get people to become more knowledgeable about, pay more attention to, and care about the foods they eat?

Congratulations. It isn't easy. I use an Iphone app as well which is helpful although I can't it has changed my weight much. As much as people get tired of the message, we have to keep trying to educate people.

Hi and thanks for taking questions.. With insurance companies not wanting to do anything BEFORE it becomes a panic problem, how do we bring down the costs of healthcare? Is that the reason why they won't cover anything until it is almost too late? It is ridiculous that insurance companies won't pay for so much until it is too late and the pharma companies just ascerbate the problem by charging so much money for meds. If they would just stop it all and think logically maybe we could get this under control. I think tho, that pharma and insurance are such big money makers that they want the money at the expense of the people who they are supposed to help. What is a concerned citizen supposed to do?

I don't think communities should be able to pass laws regulating their residents' weights/BMIs unless they provide ample facilities to help keep their residents fit. For instance, I love biking to work, but I haven't been able to do so in years because I haven't lived in cities where I feel safe doing so. I enjoy walking to the grocery store 1.5 miles away, but only .3 miles has sidewalks -- the rest of the route has me scrambling through weeds and roadside gravel. My own experience tells me that folks who live in communities without sidewalks and bike paths that actually lead somewhere -- i.e., most places these days -- are going to be hard-pressed to add fitness to their everyday routines in meaningful ways. And let's not even mention drivers who don't yield to pedestrians and seem to go out of their way to mow down bicyclists. I feel lucky that in 20 years of cycling, I have been in only one bike-car accident with no major injuries. The last time a motor vehicle hit my husband, who was biking home from work, he wound up with two broken arms. This is a complex issue with no one answer. Communities have to step up; but even more than that, we as Americans must develop the habits of courteous, observant driving, incorporating physical activity into our everyday routines, and eating what's right, not what's fast and easy. To which I say: Good luck!

I can just Amen! Obesity is a global problem anywhere the Western lifestyle has been adopted. We engineered ourselves into this problem and we have to engineer our way out of it.

What do you think of these corporate wellness programs? do you think they will reduce obesity? Do you think they should be compulsory?

I have a lot on my website about this issue. I don't think there is much evidence that they work. However, it they reinforce the message for finding ways to control weight I don't object. What I don't agree with is any penalty for individuals who are unable to lose weight. It is very hard and we need to encourage good behaviors while not penalizing those who can't reach a particular goal.

The schools now offer nutritious breakfasts and lunches to students and that has led some in the community to conclude that it's the job of the schools to provide nutritious meals and the parents can just serve convenience food and junk at home. Is there any thought to educating parents rather than just feeding their children? Teach a man to fish...

An excellent idea. You know a lot of public health campaigns, like seat-belts and smoking, worked to make children agents of change within their families. Maybe those are models we can use for obesity.

I thought that post was amusing, but it completely missed the point. National food policy encourages -- almost forces -- Americans to take in much more meat and dairy than is in any way healthy or necessary. We have reached the point, in terms of meat subsidies, at which an apple is more expensive than a double cheeseburger. Producing, "processing," transporting and packaging a pound of meat takes, in total, more than 20 times the amount of water consumed by a pound of fruit or vegetables. The meat industry needs to be called out on this, and there's no legitimate basis for meat-related government subsidies (without which there would not be a mass-consumption meat industry in the US).

I understand your point but it is not meat alone which is causing the obesity epidemic.

Can you give me an example of a good way for government to create an incentive to healthy eating without trampling on the rights of Americans to consume what they choose?

Sure. There are several. One is to subsidize fruits and vegetables so that their prices are more competitive with prepared food. The second is to change the Nutritional Label which is easily manipulated. I've suggested 'front of package' calorie information so that you would see foods with something like 240/out of a recommended 2,000 calorie a day. The Food and Drug Administration is looking into that change right now.  

Seriously - personal responsibility is the choice there. I agree, some are destined to be heavy, however, all of people are making the wrong choices. Since I am in my middle 60's, I can say with certainty that people didn't have all the processed foods "back in the day" and kids were outside all the time playing when not in schools. We ate food that came from plants, soil and animals. Today's people think eating an entire box of low-fat cookies is their way of watching what they eat. That old saying goes - you are what you eat... and how much of it.

I'm in your demographic so I know what you mean. However,  nostalgia for how it was is a poor roadmap for going forward. Remember in those days that women were expected to be home cooking and shopping. Many families don't and can't live that way anymore

Do you think the Childhood Obesity initiatives of Michelle Obama and Bill Clinton are doing any good? or are they mainly for PR? How about Huckabee? Is he for real?

I think it is too early to tell about Michelle Obama's program. It certainly has promise. Clinton Foundation has done some good work but stil a work in progress. All these voices reinforce the need for personal and social action to attack this problem.

Bartenders are forbidden from serving alcohol to people who are obviously intoxicated. Could the same be done with obesity? Could restaurants be allowed to ban overweight people from ordering anything but the most nutritious meals and could supermarkets likewise be forbidden from selling high-calorie foods to people who were obviously overweight?

Not likely. I don't think those ideas would work. Keep in mind that even a person with obesity experiences hunger. Probably obese individuals have greater levels of hunger than normal weight persons. And the effect of hunger, the cravings, attention to food, are the same. So people will find ways to find relief from hunger. Prohibition didn't work for alcohol and it is unlikely to work for food consumption.

Judging from the questions submitted today, would we benefit from a change in terminology? Would the same people decrying efforts to combat obesity be as opposed to efforts to combat cancer, heart disease, Alzheimers, diabetes, and other chronic diseases that are linked to obesity?

Couldn't agree more. We need to recognize obesity as a disease in its own right.

Insurance companies are as much to blame as anyone. When I asked Anthem BCBS if I could see a Dietician because diabetes runs my family as we get older and I wanted to make sure that I was making the right choices in changing my eating habits to avoid the problem (which I currently don't have) and they said it would NOT be covered. Only if I was diagnosed as being diabetic it would be covered. How stupid is that.

Stupid and very typical. As I said, the insurance industry does a very poor job at intervening early to prevent chronic diseases, like obesity, diabetes and heart disease.

On Washington Post's home page this morning, it mentioned the increase in obesity since 1996. I found this an extremely convenient year to use for comparison, since the obesity standards were redefined in 1998. People went from normal to overweight and from overweight to obese without actually gaining an ounce, simply as a result of the redefinition. Far too many stories compare pre-1998 numbers with post-1998 numbers and never bother to mention that the definitions were changed during the comparison period. Instead the stories, whether out of ignorance or out of a willful attempt to misconstrue the statistics, quietly compare apples to oranges. I am not saying that we do not have an obesity issue in the U.S. We most certainly do. But just as with any other issue, experts and the media have a responsibility to accurately represent the data, and that includes disclosing when the yardstick has changed. Your thoughts?

I agree. The problem is that we can get into some very complex statistical areas. This has been the case with trying to define childhood obesity. The older, long-term data has some flaws as well which later studies bring out.

As someone who has struggled with my weight most of my life, I have great doubts that anything the government can do, or wants to do, will have much effect on obesity. I only started to get my weight down to proper levels when I made a personal commitment to eat properly and exercise. Without that personal commitment, no calorie information or banning of X, Y, or Z in restaurants would have made any difference whatsoever, because I didn't care about what I put in my mouth. I don't see how the government is an adequate substitute for personal commitment to losing weight. Ban cookies from school, the kids will eat them outside school and on the sly, just like they still continue to smoke cigarettes on the sly. Until kids make the commitment, the government's involvement is not going to work.

I think there is a difference between helpful government action and unhelpful action. Expanding research on obesity and funding more efforts to reach children and adolescents early before they start to put on weight can help.

In This Chat
Morgan Downey
Morgan Downey, J.D., is an obesity policy consultant and publisher/editor of "The Downey Obesity Report": www.downeyobesityreport.com. He was formally head of the Obesity Society.
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