Exercising their influence

Healthcare providers and insurers are moving onto the front lines of the nation's war on obesity as policymakers' efforts flounder.

Last week, New York City Mayor Michael Bloomberg's aggressive move to target alarming rates of obesity hit a significant roadblock when a judge struck down his limits on large-sized sugary drinks just one day before the controversial rules were supposed to go into effect.

The setback—and the barrage of criticism the effort drew from the food and beverage industries—illustrates the fight policymakers have on their hands as they try to craft legislation aimed at stemming some of the sources of obesity and its related health impacts.

In the face of uneven legislative progress, many hospitals and health systems are tackling the obesity epidemic head-on, particularly as emerging payment models make them more accountable for controlling costs and improving outcomes.

Viewed as a leading cause of preventable death, obesity, or excess body fat, is associated with a host of poor health outcomes, including higher rates of heart disease, osteoarthritis, Type 2 diabetes and some cancers. The problem is compounded by a number of hard-to-address factors, including lack of access to nutritious food in many urban and rural areas and low socio-economic status.

Hospitals and physicians have traditionally stuck to doling out simple advice about exercise and healthy eating when confronted with obese patients. But that hands-off approach is quickly becoming a thing of the past.

For instance, Jacksonville, Fla.-based Nemours, which is one of the country's largest children's health systems, has had a weight management program in place for patients in Delaware for more than 20 years. In response to a growing prevalence of obesity in Florida, Nemours created a sister program there in an outpatient setting six years ago called Healthy Choices Clinic, which provides dietitians, mental health counselors, nurses and exercise specialists who can tailor programs that meet the needs of young people struggling with their weight.

Kids who stay with the program for longer than a year have seen a reduction in their body mass index, a measurement that indicates if a person is overweight or obese, according to Dr. Lloyd Werk, who has run the clinic since its inception. “Whether the health consequence is walking down the road to Type 2 diabetes, or sleep apnea, or Blount's disease (a disorder of the growth of leg bones), there's increasing recognition that being obese and overweight is not without consequences,” Werk said.

In January, the Academic Pediatric Association granted Nemours a two-year provisional accreditation for physician obesity fellowships, the first program that centers specifically on pediatric obesity. “Health systems need qualified, well-trained people to meet the needs of an overweight population,” Dr. George Datto, director of the fellowship, said in a statement after the announcement. And the system's newly built Nemours Children's Hospital, Orlando, Fla., features KidsTRACK, a family research center that includes a teaching kitchen where parents can learn how to prepare healthy meals for their children.

Sentara Williamsburg (Va.) Regional Medical Center is using its parent system's ownership of an insurance company to bolster its population health management efforts, said Bob Graves, president of the 145-bed hospital. Ten-hospital Sentara Healthcare owns Optima Health, a health plan.

Norfolk, Va.-based Sentara has also used the plan to target its own employees who struggle with obesity-related diabetes and other chronic conditions. It uses quarterly appointments with health coaches and offers premium-lowering incentives for participation. Optima Health has also launched obesity-related initiatives for non-employee members, he added.

These stepped-up efforts by providers and insurers take place against a backdrop of obesity rates that have risen substantially in recent decades and show few signs of receding despite heightened national consciousness about its health impact. The Centers for Disease Control and Prevention reports more than one-third of adults and almost 17% of youth in the U.S. were obese in 2009 and 2010, and there had been no change in the prevalence of obesity among adults or children from 2007-08 to 2009-10.

Healthcare costs related to obesity nearly doubled to about $147 billion in 2008 from roughly $75 billion in 1998, according to Terry O'Toole, senior adviser in the CDC's division of nutrition, physical activity and obesity. Meanwhile, the average American adult is 25 pounds heavier today than the average adult was in 1960.

O'Toole said the campaign to address obesity began around 2004 and got a shot in the arm when first lady Michelle Obama launched the Let's Move campaign, her well-advertised effort to move kids away from television and computer screens and onto playgrounds and dance floors. “No doubt we've seen more activity with Let's Move,” O'Toole said. However, it's essential to adopt broader strategies that improve the environment in ways that make healthy living easier, he said. For this to happen, communities need to determine what changes are necessary to boost physical activity in schools, promote safe options for bicycle transportation and provide access to nutritious foods.

Trust for America's Health, which advocates for the nation's public health departments, has pushed for such a broader approach to address the obesity problem in America. Jeff Levi, the group's executive director, said an effective strategy involves three components: cultural change, which is seen through the first lady's campaign; programs and interventions, such as the diabetes prevention program developed from a National Institutes of Health study and now being implemented at YMCAs; and policy changes that encourage people to make healthier choices, such as nutrition standards in school lunch programs and menu labeling at restaurants, which the Patient Protection and Affordable Care Act will require nationwide.

“Over the last five years, we've seen a start of the programs and policies and activities that will alter the trajectory,” Levi said. “We're not seeing that yet in a significant way with the numbers, but that takes time.”

It also continues to face stiff opposition, which makes legislative strategies difficult to execute. New York City's proposed limits were an attempt to curb the public's intake of soda, which health experts say contributes significantly to obesity. But in his 37-page ruling in favor of New York City restaurateurs, Justice Milton Tingling called the beverage rules—which would have capped the size of sugared drinks served at restaurants, stadiums, food trucks and movie theaters to 16 ounces—“arbitrary and capricious” and full of loopholes that exempted many sugary drink vendors while targeting others. He also concluded that the city's Board of Health did not have the authority “to limit or ban a legal item under the guise of 'controlling chronic disease.'”

The American Beverage Association, an industry group that had vigorously protested the drink limits, issued a statement saying the judge's ruling had provided a “sigh of relief to New Yorkers and thousands of small businesses that would have been harmed by this arbitrary and unpopular ban.”

Bloomberg last week pledged to fight the ruling. New York has one of the more significant obesity problems in the nation with over 57% of adults and nearly 40% of children classified as overweight or obese, according to state health department data.

Some advocates of government-led efforts to fight obesity are predicting Bloomberg, who also led the way on requiring calorie counts on menus, will ultimately be successful. “I wouldn't count out Mayor Bloomberg and the New York City health department quite yet,” said Michael Jacobson, executive director of the Washington-based advocacy group Center for Science in the Public Interest. “We are confident that the city will prevail here. Many years hence, people will look back and think it was crazy for sugar drinks to ever be served in 32- and 64-ounce pails.”

Healthcare providers, who are already dealing with the health impact of the obesity epidemic as payment models move toward capitation, don't have that long to wait. Efforts to coordinate care at Grady Memorial Hospital, Atlanta, for instance, are focusing on diabetics and patients who struggle with congestive heart failure.

The safety net hospital is planning to develop a program for obesity, which is a primary cause of diabetes, said Shannon Sale, Grady's vice president for planning and business development.

The program will be operated though Grady's primary-care clinics, which are also partners with nearby federally qualified health centers in a Medicare accountable care organization. Under the ACO, Grady will encourage diabetics to exercise and monitor their weight and diet. The accountable care partners are also considering patient incentives for healthy behavior and for adhering to scheduled checkups.

At Yale New Haven Health System's Bridgeport (Conn.) Hospital, local primary-care providers, public agencies and civic groups launched a public health campaign to reduce obesity. It is asking area employers to support and promote healthy eating and exercise. “To change behavior for a community you really have to hit it from all sides,” said Lyn Salsgiver, vice president for strategy and business planning at the system. “For us as a country to change the way we think about healthy eating and physical activity, we have to change the culture.”

TAKEAWAY: Hospitals and physicians are taking up the obesity fight as policymakers struggle to get traction.

—with Melanie Evans, Beth Kutscher