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Community Solutions to the Challenges of Childhood Obesity November 4, 2005 “ It’s easier to build a child than fix an adult .” Eduardo J. Sanchez, M.D., MPH Commissioner, Texas Department of State Health Services. Environmental Perspectives #1.

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Community Solutions to the Challenges of Childhood Obesity November 4, 2005“It’s easier to build a child than fix an adult.”Eduardo J. Sanchez, M.D., MPHCommissioner, Texas Department of State Health Services
environmental perspectives 1
Environmental Perspectives #1
  • An aging population with increasing medical care costs
  • An increasing Hispanic population
  • An epidemic of obesity
  • An explosion of type 2 diabetes
  • A significant # of Texans with mental illness and/or substance abuse conditions
environmental perspectives 2
Environmental Perspectives #2
  • A shortage of healthcare providers
  • Wide, & in some cases, growing health disparities
  • The challenge of improving health literacy
  • The highest % of residents without health insurance
  • Compelling reminders Texas must be prepared for natural and man-made disasters
three guiding principles
Three Guiding Principles

Sound Mind, Sound Body

Prevention first, treatment if necessary


adverse childhood experiences ace study
Adverse Childhood Experiences (ACE) Study
  • In the mid-1980s Kaiser Permanente conducted an obesity program
  • In trying to understand the program’s high dropout rate, they conducted detailed life interviews of almost 300 individuals
  • Researchers discovered that sexual abuse was common among dropouts, & that abuse always predated obesity
adverse childhood experiences ace study1
Adverse Childhood Experiences (ACE) Study
  • As a follow-up, Kaiser Permanente & CDC conducted ACE study
  • Study involved 19,000 mostly middle class, middle aged adults
  • Results show childhood abuse & household dysfunction led to chronic diseases decades later
  • Traditionally viewed as public health problems, behaviors may also be coping mechanisms
Adverse Childhood Experiences
  • Trauma in Child’s
  • Household
  • Substance Abuse
  • Parental divorce
  • Mentally ill or suicidal household member
  • Violence to mother
  • Imprisoned household member

Child Abuse or Neglect

  • Physical abuse
  • Sexual abuse
  • Abandonment
Adverse Childhood Experiences
  • Health Risk Behaviors
  • Smoking
  • Obesity
  • Suicide
  • Alcoholism
  • Drug abuse
  • Sexually transmitted disease
  • Self-injury
  • Eating disorders

Effects of Trauma

  • Difficulty controlling anger
  • Hallucinations
  • Depression
  • Panic reactions
  • Anxiety
Adverse Childhood Experiences

Long-Term Consequences

  • Social Problems
  • Homeless
  • Prostitution
  • Delinquency, violence and criminal behavior
  • Re-victimizations: rape; domestic violence
  • Un-Employment
  • Inter-generational transmission of abuse

Disease and Disability

  • Heart disease
  • Cancer
  • Chronic lung disease
  • Emphysema
  • Mood disorders
  • Anxiety disorders
Adverse Childhood Experiences

& Intravenous Drug Use

Adverse Childhood Experiences





Disability, and

Social Problems

Adoption of

Health-risk Behaviors

Social, Emotional, &

Cognitive Impairment

Adverse Childhood Experiences


II. The “Education” Context

What you don’t know can kill you.

texas high school graduation rate 2002 2003

Texas High School Graduation Rate2002 - 2003

Source: Texas Educations Agency AEIS Report

education the greatest predictor of longevity
Education: The Greatest Predictor of Longevity
  • The overall death rate for people 25- 64 with less than 12 years education is more than twice that for people with 13 or more years of education.
    • Less than 12 years of education: 615.6 deaths per 100,000
    • 13 or more years of education: 207.9 deaths per 100,000
  • The lower the education level, the greater the likelihood that individuals will engage in unhealthy behaviors.

CDC National Center for Health Statistics, Vital Statistics Vol. 53, #5, Deaths, 2002

prevalence of obesity by education
Prevalence of Obesity by Education

Source: American Journal of Preventative Medicine, 2004;27 (3S)

health literacy
Health Literacy

Most medical information on internet written at12th grade level

Average American reads at 8th-9th grade level

Average Medicaid recipient reads at 5th grade level

III. The “Economic” Context

Are we getting our money’s worth?

growth in national health expenditures 1980 2011 from 1 000 to 9 000
Growth in National Health Expenditures 1980–2011 from $1,000 to $9,000



Per Capita Costs

Levit et al. Health Affairs 2002;21:172–181.

*Projection from Heffler et al. Health Affairs 2002;21:207–218.

the rising spiral of health care costs
The Rising Spiral of Health-Care Costs
  • Healthcare premiums are growing more than 3 times faster than workers’ wages and 2.5 times faster than the inflation rate
  • Percentage of employers providing health benefits
    • 2000 69%
    • 2005 60%
  • Healthcare cost increases (national):
    • 2005 9.2%
    • 2004 11.2%
    • 2003 13.9%

2005 Kaiser Foundation Survey

the rising spiral of health care costs1
The Rising Spiral of Health-Care Costs
  • State of Texas employee health care costs up 53% since 2000
  • Health care now consumes 30% of total state budgets*
  • Medicaid alone accounts for 20%*

*National Governor's Association Center for Best Practices

the price is not right
The Price is Not Right

The U.S. Ranks:

Health Care Spending 1st

Life Expectancy 28th

U.S. $1.79 Trillion

Source: The World Health Report 2003, Total Population at Birth.

IV. The “Conceptual” Context

Are we going to redefine health care to include medical care


public health?

causes of death in united states 2002
Causes of Death in United States – 2002

Actual Causes of Death2

Leading Causes of Death1

Heart Disease


Poor diet/lack of exercise3




Chronic lower respiratory disease

Infectious agents


Unintentional Injuries






Alzheimer’s disease

Motor vehicles

Illicit drug use

Kidney Disease

Percentage (of all deaths)

Percentage (of all deaths)

Sources: 1 National Vital Statistics Reports, Vol. 53, No. 15, February 28, 2005.

2 Adapted from McGinnis Foege, updated by Mokdad et. al., 2000.

3 JAMA, April 20, 2005—Vol 293, No. 15, pg 1861.

increased life expectancy
Increased Life Expectancy

Increased years due to

public health measures:


Increased years due to

medical care advances:


Source: Centers for Disease Control and Prevention (CDC).

the healthcare equation is out of balance



More Sedentary

Un & Underinsured

Health Illiterate


Increasing Access

Improving Quality of Care

Improving Technology

Improving Meds

Improving Workforce

The Healthcare Equation is Out of Balance

Demand Reduction Is Imperative

the healthcare equation is out of balance1

Increasing Access

Improving Quality of Care

Improving Technology

Improving Meds

Improving Workforce

The Healthcare Equation is Out of Balance



Demand Reduction Is Imperative

V. The “Obesity” Challenge

Is it really that serious?

Obesity Trends Among U.S. Adults




No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

BRFSS, 1991, 1996, 2004

2005 texas is 6 th most obese state each state more than 25 obese
2005 Texas is 6th Most Obese Stateeach state more than 25% obese
  • Mississippi
  • Alabama
  • West Virginia
  • Louisiana
  • Tennessee
  • Texas, Kentucky, Michigan

“How Obesity Policies are Failing in American” Trust for America’s Health August 2005,

preventing childhood obesity health in the balance
Preventing Childhood Obesity- Health in the Balance

“Despite steady progress over most of the past century toward ensuring the health of our country’s children, we begin the 21st Century with a startling setback—an epidemic of childhood obesity.”

- Institute of Medicine

prevalence of at risk and overweight in texas children 2001
Prevalence of At Risk and Overweight in Texas Children, 2001

* At risk of overweight is >85th but <95th Percentile for BMI by Age/Sex

**Overweight is > 95th Percentile for BMI by Age/Sex

Causes of Overweight/Obesity
  • Too many calories in; too few calories burned
  • 1977-1993 Average daily food intake increases by almost 200 calories
  • 1960 McDonalds serving of Fries = 200 calories
  • 2000 McDonalds serving of Fries = 610 calories

New England Journal of Medicine, 5/22/03 review of “Fat Land” by Greg Critser

overweight and obesity pediatric conditions affecting children
Overweight and Obesity-Pediatric Conditions Affecting Children
  • Type 2 Diabetes Mellitus
  • High Blood Pressure
  • High Cholesterol
  • Gallbladder Disease
  • Sleep apnea
  • Behavioral Health Problems

Source: Overweight and Obesity Health Consequences. National Center for Chronic Disease Prevention and Health Promotion.

Three Disturbing Trends

Obesity and Diabetes: CDC NHANES; Expenditures: CMS, Health 2004

who will develop diabetes
Who Will Develop Diabetes?

1/3 of American children

2/5 of blacks & Hispanics

1/2 of Hispanic females

Diabetes: Almost $1 of every $5 spent on health care in the U.S. is for a person with diabetes

Source: *Diabetes Care, Volume 26, Number 3, March 2003, p926

cost of diabetes in texas
Cost of Diabetes in Texas

~1.5 millionTexans with diabetes

$13,240* Annual medical costs with diabetes

$ 5,640* Age-adjusted average annual per person costs without diabetes

$ 7,600 Added cost due to diabetes per person

$11.4 billion Added cost to treat 1.5m Texans

with diabetes

: *Diabetes Care, Volume 26, Number 3, March 2003

projected diagnosed diabetes in the u s
Projected Diagnosed Diabetes in the U.S.

Projected number of people with diagnosed diabetes (millions)

Population growth assumption






U.S. Census Bureau, National Health Interview Survey (NHIS), CDC, NCHS. Boyle et al. Diabetes Care, Vol. 24, No.11, November 2001.

diabetes prevention program lifestyle modification vs metformin
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

March 2005 Annals of Internal Medicine Vol. 142 #5

VI. Getting off the critical list

Some good efforts are already underway

aap overweight obesity
AAP: Overweight & Obesity
  • Prevalence in pediatric populations has reached epidemic proportions
  • Prevention is critical
  • Early recognition of excessive weight gain should be routine
  • Families should be educated to recognize the influence they have on children’s health habits
  • Dietary habits should be fostered that encourage moderation
  • Regular physical activity should be consciously promoted
pediatric obesity a clinical toolkit for healthcare providers
Pediatric Obesity: A Clinical Toolkit for Healthcare Providers

Diagnosis Overview

Treatment Overview

Practitioners’ Tools

Patient Handouts

policy strategic plan for the prevention of obesity in texas
Policy: Strategic Plan for the Prevention of Obesity in Texas
  • 4 Goals for Obesity Prevention
    • Awareness
    • Mobilizing families, schools, and communities
    • Promote policies and environmental changes
    • Monitor obesity rates and related behaviors

state initiatives re obesity
State Initiatives re: Obesity
  • Dept. of Ag Nutrition Policy/vending machines
  • Legislative mandates to authorize physical activity through 8th grade
  • Mandatory requirement to have a School Health Advisory Council (SHAC) in every school district
  • Re-establishment of statewide SHAC
non governmental initiatives re obesity
Non-governmental Initiatives re: Obesity

Marathon Kids

  • A free endurance building running/walking nutrition program for kindergartners though 5th graders
  • children and their families run/walk 26.2 miles over a period of 6 months, at school and at home, in increments of ¼ mile at a time, until their Final Mile Medal Celebration
  • 80,000 Texas children have participated so far
dshs obesity related initiatives partnerships
DSHS Obesity-Related Initiatives & Partnerships
  • TAFP CME Kaiser Permanente video
  • Worksite wellness initiative with Building Healthy Families Coalition
  • Texas Strategic Health Partnership
  • SHAC video with Commissioners Combs & Neely
  • Community Skill-Building Trainings for promoting nutrition and physical activity
prescription for better health turn information into action
Prescription for Better Health:Turn Information Into Action
  • Eating right & staying physically active are essential to good physical & mental health
  • Increased physical activity & improved nutrition for kids
    • At home, physically active recreation
    • At school (Coordinated School Health Programs)
  • Increased physical activity & improved nutrition for adults
    • At home, model behavior
    • At work, worksite wellness
  • Schools impact communities, not just kids
cost of comprehensive school health programs
Cost ofComprehensive School Health Programs

4,258 Texas Public Elementary Schools

$2,500 Average Cost for Coordinated School Health


x 2500


1 prevented cases of diabetes/year per school = $32 million

what happens when schools take action to make a difference
What Happens When Schools Take Action to Make a Difference?
  • Improved academic performance
  • Higher self-esteem for students
  • Lower absentee rates
  • Fewer behavioral problems
  • Higher school morale
  • Behaviors, values & knowledge that can sustain a healthy life for our children
washoe county isd in nevada 6 600 employees spent 1 million on gastric bypass surgeries
Washoe County ISD in Nevada (6,600 employees) spent $1 million on gastric bypass surgeries

$25,000 surgery

x 1,000,000

$25 Billion

morbidly obese Texans

  • On average, 2002 health-care costs for an obese person were $1,244 higher than for a person with a healthy weight
5 simple rules
5 Simple Rules
  • Eat smart
  • Be active
  • Sleep plenty
  • Don’t smoke
  • Stay connected