Heartland Health Research Institute

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Obesity – a Disease or a Choice? (Part 3)

By: David P. Lind

The public often views obesity as a failed lifestyle stemming from poor diet and little physical activity. Yet, research ties obesity to a variety of genetic, metabolic, hormonal and systemic factors that predispose individuals to obesity.

According to a 2016 report from NORC at the University of Chicago, almost half of Americans (48 percent) tend to believe that obesity is not a disease – it is caused and perpetuated by a person’s lifestyle choices (eating and exercise habits). In fact, the biggest barrier to weight loss, they believe, is largely due to lack of willpower, laziness, lack of self-control – all untrue stereotypes.

During the past 18 months, COVID-19 has increased awareness of obesity. This is because obesity has been identified as a risk factor for severe COVID-19 symptoms. People are increasingly expressing concern about gaining weight during the pandemic, the so called “quarantine-15.”

Genetics, Environment, Behavioral and Emotional

Researchers, however, have found that obesity, which affects at least one-third of Americans, is not caused by sloth and gluttony. According to The Centers for Disease Control and Prevention (CDC), hundreds of human genes give the body instructions for responding to changes in its environment. Individuals are attracted to inexpensive food with abundant portions. ‘Food deserts‘ are a prime example. People in a given geographical area have restricted access to affordable, healthy food options – especially fresh fruits and vegetables.  Absence of grocery stores within convenient traveling distance creates barriers to healthier eating. The CDC terms this as part of the social determinants of health, which “are conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes.”

In 2013, the medical community – including the American Medical Association (AMA) and other influential medical groups* – has generally reached a consensus that obesity is a disease. Part of the motivation for making this decision can be tied to pharmacotherapy and surgical intervention – both of which go beyond the standard lifestyle prescription of “improving diet and exercise more.”

Although experts have divergent views on the science of losing weight, it is the consensus of medical experts that obesity is caused by a combination of genetic, environmental, behavioral, and emotional factors. Some illnesses, such as Cushing syndrome and polycystic ovary syndrome, may lead to weight gain and obesity. Using steroids and specific antidepressants can also cause weight gain.

The Stigma of Obesity Must End

‘Lack of willpower’ is not a valid cause of obesity. It is a form of shaming based on uneducated philosophies and beliefs. Labeling obesity as simply being an individual lifestyle ‘choice’ has no scientific basis. Such stigmatization threatens the health of obese individuals, generates health disparities, and just as importantly, interferes with effective intervention efforts.

Obesity can effect individuals regardless of gender, job title, education, age, location, or political preference. However, there are known disparities in obesity rates based on race/ethnicity, gender, and socioeconomic status. The stigma, prejudice and discrimination that is pervasive in the workplace, healthcare facilities, educational institutions, mass media and other places perpetuates a narrative that it is socially acceptable to negatively stereotype obese individuals. Some argue that this stigma will help serve as a useful tool to motivate obese people to adopt healthier lifestyles…this thought process is grossly misguided.

A June 2010 paper, “Obesity Stigma: Important Considerations for Public Health,” published in the American Journal of Public Health, takes a deep dive into this issue. Obesity is a public health priority. The resultant suffering and comorbidities require local and national discourse addressing this epidemic. In short, the stigmatization of obesity is not an effective way of addressing this disease.

Summary

As mentioned in “Obesity Requires Employer Attention and Focus – (Part 1)” in this blog series, a new employer mindset must evolve to alter the alarming trajectory of the obesity epidemic. Employers have a fundamental interest in addressing this persistent health crisis. The final two segments of this obesity series will focus on approaches employers might consider when addressing obesity.

* World Health Organization; National Institutes of Health; Centers for Medicare and Medicaid Services; Obesity Society; Institute of Medicine; and American Association for Clinical Endocrinology.

This post is the third in a five-part series. Click here to read “Obesity Requires Employer Attention and Focus – (Part 1)” and “Is the Body Mass Index (BMI) Useful? (Part 2)“.

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Obesity Requires Employer Attention and Focus – (Part 1)

By: David P. Lind

Employers have a great deal on their plates, and much of it relates to the ongoing COVID-19 pandemic. Attracting and retaining workers has always been a challenge, but the pandemic-ravaged economy has nudged this to a whole new level of urgency. The COVID virus dangerously challenges the workplace in another way, and it requires long-term thinking by employers. 

This challenge relates to obesity.

Obesity

As we have learned during the past 20 months of the pandemic, obesity is a worrisome risk factor for hospitalization and death for those with COVID-19. A March 2021 Morbidity and Mortality Weekly Report, prepared by the Centers for Disease Control and Prevention (CDC), revealed evidence of a relationship found between body mass index (BMI) and COVID-19 severity. Obesity rates have nearly tripled in the U.S. over the last 50 years (Source: USA Facts).

The CDC uses the BMI scale that relates weight with height to determine obesity level. For adults, a BMI over 30 qualifies as obese. It should be noted that BMI is not a perfect measure of one’s current health. More about this in the next blog.

COVID-19 highlights the many risk factors for people who are both overweight and obese. For employers, these risk factors should be of great concern when promoting a healthy and productive workforce. In fact, employers must double-down on their efforts to confront this long-term threat to the wellbeing of employees. Pandemic or not, the associated risks with having high-BMI numbers will not go away any time soon.

Iowa Obesity Rates

Based on new CDC 2020 Adult Obesity Prevalence Maps of 50 states, Iowa adults are in the top 16 states having the highest rate of obesity (35 percent or more). A 2018 survey by The Behavioral Risk Factor Surveillance System (BRFSS), which is part of the CDC, found that almost 70 percent of adult Iowans are considered to be either overweight or obese. Put another way, 34.1 percent are overweight while another 35.3 percent are obese. However, 2020 data reveals that Iowa’s obesity rate has risen to 36.5 percent. This new map shows how Iowa compares to all other states, including the District of Columbia and two U.S. territories. 

Data from the 2020 U.S. Census Bureau shows that Iowa’s population was 3,190,369, of which 77 percent are adults aged 18 and over (2,456,584 total). Using 2018 BRFSS data, this means approximately 867,174 Iowa adults live with obesity, while another 837,695 have BMI numbers between 25.0 to 29.9 – which is considered overweight.

According to ConsumerProtect, which used CDC-based data, adult Iowans tend to move a bit more than their counterparts from other states, with ‘only’ 25 percent of adults engaging in zero physical leisure activities – ranking Iowa as the 31st state having the highest percentage of adults engaging in no activity. Kentucky was the state with the highest percentage of adults reporting no activity (34.4 percent).

Impact on Individuals and Employers

The risk factors of having a higher-than-healthy BMI number comes at a substantial cost. The aforementioned risk factors for obesity and excess weight on the individual include, but are not limited to, the following:

  • All-causes of death (mortality)
  • High blood pressure (Hypertension)
  • High LDL, low HDL cholesterol, or high levels of triglycerides
  • Type 2 diabetes
  • Coronary heart disease
  • Stroke
  • Many types of cancer
  • Mental illness such as clinical depression, anxiety, and other mental disorders
  • Body pain and difficulty with physical functioning

According to a 2016 report by Wellmark, “The Health of Iowans,” obesity is a common factor that contributes to the most costly conditions among Wellmark’s members in Iowa. For employers, obesity is both a sensitive and challenging issue and varies by industry. The associated costs for obesity are primarily twofold: 1) treatment-related expenses, and 2) reduced worker productivity.  Treatment expenses are typically covered by employer-sponsored health insurance and workers compensation while reduced worker productivity adversely impacts employers through absenteeism, presenteeism and wage replacement due to disability. Together, both represent a drag on productive output and profitability – which adversely impacts local and state economies.

A 2014 report in the American Journal of Health Promotion found that an obese employee with a BMI of 35 has nearly double the risk of filing a short-term disability claim or a workers’ compensation claim than an employee with a BMI of 25. This report also revealed that morbidly obese employees cost an average of $8,067 per year in covered medical claims, sick days, short-term disability and workers compensation, which is more than double the cost for normal-weight employees ($3,830). 

According to a 2018 Milken Institute report, the chronic diseases that result from obesity and excess-weight were estimated to cost more than $480 billion in direct healthcare costs and $1.24 trillion in indirect work loss costs in the U.S. Together, both costs are equivalent to 9.3 percent of the U.S. gross domestic product (GDP).

Summary

The pervasive nature of an overweight and obese population is a profound challenge to all Americans and to employers. Changing behaviors on dietary and physical activity is the desired goal, but is often met with disappointing results. 

Depending on how incentives and disincentives are aligned with desired outcomes, implementation of wellness programs have had limited success for employers. Organizations must develop new, targeted approaches that are sensitive to their employees, yet impactful enough to provide positive outcomes.

My next installment will focus on the criticisms of BMI and its use as a measure of health.

This post is the first in a five-part series.

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The Lure of Opioids

By: David P. Lind

The Lure of Opioids

One medical topic clearly on today’s radar is the use (and abuse) of opioids – medications that are often used to relieve pain, such as: hydrocodone (e.g. Vicodin), oxycodone, morphine, codeine and other related prescription drugs.

It is relatively easy to become addicted to opioids. Like many others, I have been prescribed various opioids (typically Vicodin) in the past when having lower back pain or a dental procedure that required pain management. Thankfully, I used only a very small portion of the prescribed pills during each incident, which resulted in the accumulation of many ignored (and expired) bottles in our medicine cabinet.

For many, the continued use of opioids to control pain may quickly evolve into a habit, and eventually, addiction. Without seeking and receiving appropriate rehabilitation for opioid addiction, accidental deaths happen far too often. In 2014 alone, the number of opioid deaths due to overdose in the United States was 28,647, a number that exceeds the size of Marshalltown, Iowa’s 16th most populated city. A 14 percent increase from 2013, this number represents an age-adjusted rate of 9.0 Americans per 100,000.

Iowa Opioid Fatalities

The Kaiser Family Foundation analysis shows that 158 opioid fatalities occurred in Iowa during 2014. With an adjusted death rate of 5.3 Iowans per 100,000, Iowa ranks considerably below the U.S. average. The adjusted rates of fatalities per 100,000 for each of Iowa’s six neighboring states are listed below:

  • Nebraska – 3.2 (56 fatalities in 2014)
  • South Dakota – 4.1 (33)
  • Minnesota – 6.0 (318)
  • Illinois – 9.4 (1,205)
  • Wisconsin – 11.1 (627)
  • Missouri – 12.0 (696)

The below-average rates for Iowa, Nebraska, South Dakota and Minnesota leads one to ask, “What are these states doing differently?” Have these states implemented actions preventing individuals from becoming addicted and treating those who are addicted? Do they have narcotics detectives and emergency medical technicians who help guide individuals to treatment rather than arrest them? Some states have indeed implemented programs to address this emerging topic of national concern.

The Center for Disease Control and Prevention (CDC) recently released guidelines to help physicians prescribe opioids appropriately and responsibly. The opioid crisis should not just be the concern for providers who prescribe opioid medication. In fact, everyone has a role to play mitigating this epidemic, including those addicted and their family members, those who treat the addicted, educators, law enforcement agencies, and the efforts of a well-coordinated community. As two authors commented in a recent Health Affairs publication, the opioid crisis is “a multi-faceted problem [that] requires a multi-faceted solution.”

For each of us, a frequent reconnaissance of our medicine cabinets to ‘search and safely dispose’ is a good first step to eradicating opioid misuse and abuse.

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Preventable Fatalities in Hospitals
Gathering the Right Statistics

By: David P. Lind

Silent Death: Approximately 252,000 patients die annually in hospitals due to preventable medical mistakes.

Silent Death: Preventable medical errors in hospitals.

A recent report published in The BMJ by Dr. Martin Makary and Michael Daniel, both from Johns Hopkins University School of Medicine, generated a great deal of national exposure from the mainstream media – and for good reason. We have known for years that fatalities due to preventable mistakes made in U.S. hospitals are enormous. In fact, medical errors are the third-leading cause of death in this country, behind only heart disease and cancer. But the number of medical-error fatalities are seldom reported or collected by local and national health officials.

The report estimates that about 251,000 patients die annually in hospitals due to preventable medical mistakes. However, this is considered to be a low estimate because the authors tracked only errors documented in health records, and included only hospital patients. For many obvious reasons, mostly due to malpractice and reputation concerns, medical errors are grossly underreported.

In addition to the report, the authors published a letter directed to the U.S. Centers for Disease Control and Prevention (CDC) suggesting that death certificates have serious limitations by not listing the preventable complications that contributed to the death of patients. The authors, no doubt, agree with our ‘Silently Harmed’ white papers which state “preventable harm in hospitals appears to be an epidemic, and until it is exposed and meaningful reporting methods are embraced and enforced, we have no clear process to measure improvement.”

The United States currently uses a collection system on national health statistics that does not track medical errors. Death by diagnostic and medication errors, communication breakdowns and other system errors are not counted nor included on the death certificate. This is because U.S. health statistics are based on International Classification of Disease (ICD) codes, instituted in 1949.

Bob Anderson, chief of the CDC’s mortality statistics branch, told National Public Radio recently that such reporting would be hard to change “unless we had a really compelling reason to do so.”

This particular comment struck a raw nerve with me. I can think of at least 251K+ ‘compelling’ reasons to change how we track mortality statistics in this country!

When will we finally break away from our adherence to past practices and realize that for medical outcomes to eventually improve, we must accept and embrace new priorities that will address the third-leading cause of death in the United States? For real progress to take hold in healthcare, we must first confront the brutal facts by gathering pertinent measurable statistics to serve as concrete benchmarks for future improvement.

Now that would be compelling!

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