Specialty Health Solutions Tackling Obesity and Related Lifestyle Trends

1
Specialty Health SolutionsTackling Obesity and
Related Lifestyle Trends
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Americas Health Care Crisis
3
Americas health care crisis

• 2000 prevalence data

Source Centers for Disease Control and
Prevention. (2000). Retrieved August 11, 2003,
from http//www.cdc.gov.
4
Americas health care crisis

• Heart disease
• Heart disease is the nation's leading cause of
  death.
• Claims more lives than the next five leading
  causes of death combined cancer, respiratory
  diseases, accidents, diabetes, and pneumonia.
• Almost 2,600 Americans die from cardiovascular
  disease every day (1 death every 33 seconds).
• Cardiovascular disease is responsible for 199.5
  billion in direct medical costs alone (almost
  double the economic cost of cancer).
• Three leading contributing factors tobacco use,
  lack of physical activity, and poor nutrition.

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Americas health care crisis

• Diabetes
• Type 2 diabetes accounts for 90 to 95 of all
  diagnosed cases of diabetes.
• Responsible for 100 billion in health care
  expenditures annually.
• Contributing factors obesity and sedentary
  lifestyle.

6
Americas health care crisis

• 2000 prevalence data

Source Centers for Disease Control and
Prevention. (2000). Retrieved August 11, 2003,
from http//www.cdc.gov.
7
Americas health care crisis

• Smoking
• Health Impact
• Smoking triples the risk of dying from heart
  disease.
• One year after quitting, the risk of
  cardiovascular disease declines by 50.
• Cost
• Smokers have 27 higher claims than non-smokers.
• Smoking is associated with a 21 increase in
  inpatient and outpatient spending and a 28
  increase in medications.
• Determinants
• Smokers start young, so habits are ingrained.
• Nicotine is addicting.

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Americas health care crisis

• Sedentary lifestyle
• Health Impact
• Less active people have 30 to 50 greater risk
  of developing high blood pressure
• Poor diet and physical inactivity lead to 300,000
  deaths each year.
• Moderate activity can substantially reduce the
  risk of cardiovascular disease, type 2 diabetes,
  colon cancer and can lower blood pressure and
  cholesterol, prevent osteoporosis, reduce
  obesity, and lessen symptoms of arthritis.
• Cost
• Direct medical costs associated with physical
  inactivity is 76 billion.
• Determinants
• Advances in technology have limited the bulk of
  activity to leisure time, but 26 of adults
  report no physical activity during their leisure
  time.
• Average TV and computer use is four to six hours
  per day

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Americas health care crisis

• Overweight and obesity
• Health Impact
• Overweight and obesity increases risk of heart
  disease, diabetes, high blood pressure,
  arthritis-related disabilities, and some cancers.
• Cost
• Obesity is associated with a 36 increase in
  inpatient and outpatient spending and 77
  increase in medications.
• The annual cost of obesity in the United States
  is about 100 billion overall and more the 76
  billion in direct medical costs.
• Approximately 80,000 bariatric surgeries in 2002
  costing 2.4 billion
• Determinants
• Pre-packaged, fast foods have few nutrients. For
  example, they may have less fat, but they are
  higher in total calories.
• Portion sizes have increased.
• Healthy food is the most expensive

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Obesity Trends Among U.S. Adults, 1985
WA
ME
VT
ND
MT
OR
MN
NH
ID
MA
NY
WI
SD
RI
MI
WY
CT
PA
IA
NJ
NE
NV
OH
DE
IN
IL
UT
CA
MD
WV
CO
VA
MO
KS
DC
KY
NC
TN
OK
AZ
AR
NM
SC
GA
AL
MS
LA
TX
AK
FL
No data

Less than 10

HI
Between 10 and 14

Between 15 and 19

Greater than or equal to 20
Source Behavioral Risk Factor Surveillance
System, CDC.
11
Obesity Trends Among U.S. Adults, 1990
WA
ME
VT
ND
MT
OR
MN
NH
ID
MA
NY
WI
SD
RI
MI
WY
CT
PA
IA
NJ
NE
NV
OH
DE
IN
IL
UT
CA
MD
WV
CO
VA
MO
KS
DC
KY
NC
TN
OK
AZ
AR
NM
SC
GA
AL
MS
LA
TX
AK
FL
No data

Less than 10

HI
Between 10 and 14

Between 15 and 19

Greater than or equal to 20
Source Behavioral Risk Factor Surveillance
System, CDC.
12
Obesity Trends Among U.S. Adults, 1995
WA
ME
VT
ND
MT
OR
MN
NH
ID
MA
NY
WI
SD
RI
MI
WY
CT
PA
IA
NJ
NE
NV
OH
DE
IN
IL
UT
CA
MD
WV
CO
VA
MO
KS
DC
KY
NC
TN
OK
AZ
AR
NM
SC
GA
AL
MS
LA
TX
AK
FL
No data

Less than 10

HI
Between 10 and 14

Between 15 and 19

Greater than or equal to 20
Source Mokdad, A. H., et al. (1999). Journal of
the American Medical Association, 28216.
13
Obesity Trends Among U.S. Adults, 1998
WA
ME
VT
ND
MT
OR
MN
NH
ID
MA
NY
WI
SD
RI
MI
WY
CT
PA
IA
NJ
NE
NV
OH
DE
IN
IL
UT
CA
MD
WV
CO
VA
MO
KS
DC
KY
NC
TN
OK
AZ
AR
NM
SC
GA
AL
MS
LA
TX
AK
FL
No data

Less than 10

HI
Between 10 and 14

Between 15 and 19

Greater than or equal to 20
Source Mokdad, A. H., et al. (1999). Journal of
the American Medical Association, 28216.
14
Obesity Trends Among U.S. Adults, 1999
WA
ME
VT
ND
MT
OR
MN
NH
ID
MA
NY
WI
SD
RI
MI
WY
CT
PA
IA
NJ
NE
NV
OH
DE
IN
IL
UT
CA
MD
WV
CO
VA
MO
KS
DC
KY
NC
TN
OK
AZ
AR
NM
SC
GA
AL
MS
LA
TX
AK
FL
No data

Less than 10

HI
Between 10 and 14

Between 15 and 19

Greater than or equal to 20
Source Behavioral Risk Factor Surveillance
System, CDC.
15
Obesity Trends Among U.S. Adults, 2000
WA
ME
VT
ND
MT
OR
MN
NH
ID
MA
NY
WI
SD
RI
MI
WY
CT
PA
IA
NJ
NE
NV
OH
DE
IN
IL
UT
CA
MD
WV
CO
VA
MO
KS
DC
KY
NC
TN
OK
AZ
AR
NM
SC
GA
AL
MS
LA
TX
AK
FL
No data

Less than 10

HI
Between 10 and 14

Between 15 and 19

Greater than or equal to 20
Source Mokdad, A. H., et al. (2001). Journal of
the American Medical Association, 28610.
16
Obesity Trends Among U.S. Adults, 2001
WA
ME
VT
ND
MT
OR
MN
NH
ID
MA
NY
WI
SD
RI
MI
WY
CT
PA
IA
NJ
NE
NV
OH
DE
IN
IL
UT
CA
MD
WV
CO
VA
MO
KS
DC
KY
NC
TN
OK
AZ
AR
NM
SC
GA
AL
MS
LA
TX
AK
No data

FL
Less than 10

Between 10 and 14

HI
Between 15 and 19

Between 20 and 24

Greater than 25
Source Mokdad, A. H., et al. (2001). Journal of
the American Medical Association, 28610.
17
Obesity Trends Among U.S. Adults, 2002
WA
ME
VT
ND
MT
OR
MN
NH
ID
MA
NY
WI
SD
RI
MI
WY
CT
PA
IA
NJ
NE
NV
OH
DE
IN
IL
UT
CA
MD
WV
CO
VA
MO
KS
DC
KY
NC
TN
OK
AZ
AR
NM
SC
GA
AL
MS
LA
TX
AK
No data

FL
Less than 10

Between 10 and 14

HI
Between 15 and 19

Between 20 and 24

Greater than 25
Source Mokdad, A. H., et al. (2003). Journal of
the American Medical Association, 2891.
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Americas health care crisis

• Body mass index and disease risk in women

Source Willet, W. C. (2001). Eat, Drink, and Be
Healthy (p. 36). New York Simon and Schuster
Source.
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Possible Solutions
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Possible solutions
Contributing factors to an individuals health
status
Source Centers for Disease Control and
Prevention. (2000). Retrieved August 11, 2003,
from http//www.cdc.gov.
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Possible solutions

• Womens risk of heart attack or stroke by risk
  factor status

84,129 nurses followed for 14 years.
Source Stampfer,M., Hu, F., Manson, J., Rimm,
E., Willet, W. (2000). Primary primary
prevention of coronary heart disease in women
through diet and lifestyle. New England Journal
of Medicine, 343, pp. 16-22.
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Possible solutions

• Reduction in incidence of diabetes with lifestyle
  intervention

31 reduction
58 reduction
5-7 reduction in body weight exercise 30
minutes a day. Trial was discontinued after one
year due to clear results.
Source Knowler, W. C., et al. (2002). New
England Journal of Medicine346393-403.
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Building Blocks to a Healthier Lifestyle
Effectively managing pain
Improving health habits
Effectively managing weight
Improving nutritional choices
Increasing physical activity
Reducing stress
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Program Components of Healthyroads for Living
Programs are available as non-insurance based,
health education programs.
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Evidence-based program components

• Diet and nutrition education
• Physical activity and exercises
• Behavior modification
• Convenience
• Length of treatment
• Counseling approach
• Self monitoring
• Mind-body approach

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Diet and Nutrition Education

• Energy requirements vary by sex, beginning
  weight, and level of activity.
• Melanson, K., Dwyer, J. (2002). Handbook of
  Obesity Treatment, 249-275.
• Energy deficits should be between 500 and 1,000
  kcal/d for up to two-pound loss per week.
• NIH/NHLBI/NAASO. (2000). Practical Guide to the
  Identification, Evaluation, and Treatment of
  Overweight and Obesity in Adults.
• Reduced fat and calories and fad diets can ignore
  nutritional quality.
• ADA. (2002). Position of the American Dietetic
  Assoc Weight Management.
• Nutritional quality education combined with
  energy density awareness may be best.
• Berg, F. (2000). Women Afraid to Eat Breaking
  Free in Todays Weight Obsessed World. Healthy
  Weight Network, 265-282.

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Physical Activity and Exercise

• One of the best predictors of successful
  maintenance
• Pavlou, K. N., Krey, S., Steffee, W. O. (1989).
  Exercise as an Adjunct to Weight Loss and
  Maintenance in Moderately Obese Subjects. Am J
  Clin Nut, 49, 1115-1123.
• Decreases loss of lean body mass
• Rippe, J. M., Hess, S. T. (1998). The role of
  Physical Activity in the Prevention and
  Management of Obesity. J Am Diet Assoc., 98(suppl
  2), S31-S38.
• Resistance training enhances metabolic burn
• Ballor, D. L., Katch, V. L., Becque, M. D.,
  Marks, C. R. (1988). Resistance weight training
  during caloric restriction enhances lean body
  weight maintenance. Am J Clin Nutr., 319,
  1173-1179.
• Lifestyle activity may be best to prevent regain
• Andersen, R. E., Wadden, T. A., Bartlett, S. J.,
  Zernel, B. S., Verde, T. J., Franckowiak, S. C.
  (1999). Effects of Lifestyle Activity vs.
  Structured Aerobic Exercise in Obese Women A
  Randomized Trial. JAMA, 281, 335-340.
• Registry members average one hour of moderate
  physical activity per day
• Wing, R. R., Hill, J. O. (2001). Successful
  Weight Loss Maintenance. Annu. Rev. Nutr., 21,
  323-341.

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Behavior Modification

• Methods to systematically change behavior that
  contributes to or maintains obesity
• Stimulus control change microenvironment
• Cognitive restructuring internal dialog change
• Social support
• Relapse prevention lapse is normal
  "successful relapse"
• Self-monitoring, stress management, and physical
  activity
• Foreyt, J. P., Carlos Poston, W. S. (1998). The
  role of the behavioral counselor in obesity
  treatment. J Am Diet Assoc. (Suppl 2), 10,
  S27-S30.
• Behavior modification allows maintenance of 2/3
  of initial weight loss for nine to ten months.
• Perri, M. G., Fuller, P. R. (1995). Success and
  Failure in the Treatment of Obesity Where Do We
  Go from Here? Med. Exerc. Nutr. Health, 4,
  255-272.
• Wing, R. R. (1998). Behavioral Approaches to the
  Treatment of Obesity. Handbook of Obesity,
  855-873.

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Convenience

• Phone based 35 studies (4 meta-analyses)
• Counselor-mediated programs more successful
• Equal to or more effective then face to face

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Length of Treatment

• Long-term care Length of life care.
• American Dietetic Association. (2002). Position
  of the American Dietetic Association Weight
  Management. J Am Diet Assoc., 102, 1145-1155.
• NIH recommends maintenance efforts be continued
  indefinitely.
• National Institute of Health, National Heart,
  Lung, and Blood Institute. (1998). Clinical
  Guidelines on the Identification, Evaluation, and
  Treatment of Overweight and Obesity in AdultsThe
  Evidence Report. Obes Res., 6(Supplement), 111S.
• Weight loss maintained for two to five years
  greatly increases long-term success.
• Wing, R. R., Hill, J.O. (2001). Successful
  Weight Loss Maintenance. Annu. Rev. Nutr., 21,
  323-341.
• Weight loss tends to be cyclical and is unlikely
  to be obtained in one try.
• Nonas, C. A. (1998). A model for chronic care of
  obesity through dietary treatment. J Am Diet
  Assoc. (Suppl 2), 10, S16-S22.

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Counseling Approach

• Coaching forming a relationship with members.
• Motivational interviewing moves clients to
  action by identifying discrepancies between
  current behavior and goals.
• DiLillo, V., Siegfried, N. J., Smith West, D.
  (2003). Incorporating Motivational Interviewing
  into Behavioral Obesity Treatment. Cogn Behav
  Prac., 10, 120-130.
• Motivational interviewing is especially helpful
  during plateaus.
• Early empirical data is promising.
• Smith, D. E., Heckemeyer, C. M., Kratt, P. P.,
  Mason, D. A. (1997). Motivational Interviewing to
  improve adherence to a behavioral weight-control
  program for older obese women with NIDDM A pilot
  study. Diabetes Care., 20, 52-54.

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Self-monitoring

• 22-pound weight loss in 12 weeks and 33-pound
  loss with highest level of self-monitoring.
• ONeil, P. M. (2001). Assessing Dietary Intake in
  the Management of Obesity. Obes Res., 9,
  361S-366S.
• Monitoring needs to occur more than 75 of the
  time.
• Boutelle, K. N., Kirschenbaum, D. S. (1998).
  Further support for consistent self-monitoring as
  a votal component of successful weight control.
  Obes Res., 6, 219-24.
• Staff needs to be supportive and nonjudgmental.
• ONeil, P. M. (2001). Assessing Dietary Intake in
  the Management of Obesity. Obes Res., 9,
  361S-366S.
• Use of internet and other technology aids are
  helpful.
• Tate, D. F., Wing, R. R., Winett, R. A. (2001).
  Using internet technology to deliver a behavioral
  weight loss program. JAMA., 285, 1172-7.

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Mind-body Approach

• Guided imagery
• Lorig KR, Mazonson PD, Holman HR. Evidence
  suggesting that health education for
  self-management in patients with chronic
  arthritis has sustained health benefits while
  reducing health care costs. Arthritis and
  Rheumatism.1993 April 36(4)439-446.
• Other techniques
• Abdominal breathing
• Progressive relaxation
• Present moment awareness
• Develop greater insights and ultimately change
  responses to stress
• Mannix LK, Chandurkar RS, Rybicki LA, Tusek DL,
  Solomon GD. Effect of guided imagery on quality
  of life for patients with chronic tension-type
  headache. Headache. 1999 May 39(5)326-34.
• Enhance motivation

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Healthyroads for Living Weight Management Program

• Nine months outcomes summary
• Program 116 members enrolled in telephonic
  health educators counseling program
• Initial weight 212.1 lbs (BMI 34.5)
• Final weight 206.7 lbs (BMI 33.7)
• Average BMI reduction with 4-7 sessions 2.6
• Average BMI reduction with gt 8 sessions 4.6

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Healthyroads for Living Weight Management
Program

• Percentage of decrease in meds 21
• Percentage of positive behavioral changes 63.4
  (includes increased fruits, water, vegetables in
  diet, increased exercise, and stress management
  activities)
• Lessons learned
• Intense high touch individual telephonic health
  education sessions will lead to change in
  readiness followed by change in behavior followed
  by change in heath parameters over time.

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ASH Companies