The Coming Tsunami: The Obesity Epidemic and Chronic Care

1
The Coming TsunamiThe Obesity Epidemic and
Chronic Care

• Ian Morrison

Contact_at_www.ianmorrison.com
2
Obesity Definitions

• Excess of body fat
• Body mass index (BMI) weight, kg
• height, m?
• 20-25 normal/healthy
• 25-30 overweight
• 30-40 obese
• 40 morbid obesity

3
A Few Facts...

• Obesity (BMI30) estimated 92.6 billion yearly
  (Agency for Health Research and Quality 2003)
  rivals cigarette impact Health care for obese
  individuals costs an average of 37 more than for
  people of normal weight, adding an average of
  732 to the annual medical bills of every
  American.
• Obese have a 50-100 increased risk of death,
  risk for cancer,coronary heart disease,
  musculoskeletal disease and high risk for Type
  2 DM
• Morbid obesity defined as BMI40, or BMI35 with
  co-morbid conditions (Type 2 DM, GERD, HBP,
  osteoarthritis, OSA).
• 9 of 9-11 month old infants eat French fries on
  a daily basis (SF Chronicle)
• US produces 4000 calories/person/day

4
Percentage of U.S. Adults Overweight and Obese
Overweight
Obese
Severely Obese
65
1999-2002
30
4.7
56
1988-1994
23
2.9
47
1976-1980
15
No data
Source Centers for Disease Control and Prevention
5
The Cost of Obesity
Increases in the proportion of and spending on
obese people relative to people of normal weight
account for 27 of the rise in inflation-adjusted
per capita spending between 1987 and 2001
spending for diabetes, 38 spending for
hyperlipidemia, 22and spending for heart
disease, 41. Increases in obesity prevalence
alone account for 12 of the increase in health
spending. Source Thorpe et al, Health
Affairs,Web Exclusive, 10/20/04
6
(No Transcript)
7
Obesity by Income
8
Obesity Trends Among U.S. AdultsBRFSS, 1985
(BMI ?30, or 30 lbs overweight for 54 woman)
9
Obesity Trends Among U.S. AdultsBRFSS, 1986
10
Obesity Trends Among U.S. AdultsBRFSS, 1987
11
Obesity Trends Among U.S. AdultsBRFSS, 1988
12
Obesity Trends Among U.S. AdultsBRFSS, 1989
13
Obesity Trends Among U.S. AdultsBRFSS, 1990
14
Obesity Trends Among U.S. AdultsBRFSS, 1991
15
Obesity Trends Among U.S. AdultsBRFSS, 1992
16
Obesity Trends Among U.S. AdultsBRFSS, 1993
17
Obesity Trends Among U.S. AdultsBRFSS, 1994
18
Obesity Trends Among U.S. AdultsBRFSS, 1995
19
Obesity Trends Among U.S. AdultsBRFSS, 1996
20
Obesity Trends Among U.S. AdultsBRFSS, 1997
21
Obesity Trends Among U.S. AdultsBRFSS, 1998
22
Obesity Trends Among U.S. AdultsBRFSS, 1999
23
Obesity Trends Among U.S. AdultsBRFSS, 2000
24
Obesity Trends Among U.S. AdultsBRFSS, 2001
(BMI ?30, or 30 lbs overweight for 54 woman)
25
Lifestyle Changes that Promote Sedentary Behavior
26
Obesity Drivers

• We are eating more (duh!)
• We are eating out more (In 1970 34 of the food
  budget was consumed outside the home in late
  1990s it was 47)
• Everything is supersized at home and at McDonalds
• We stopped smoking
• We are all working too much especially women
• We dont exercise enough because we are all
  working too much
• The only people who are exercising and eating
  right are people who were thin in the first place
  or bulemic celebrities or rich people who dont
  work or French

27
Supersize Everything Part 1
National Geographic August 2004
28
New Monster Thickburger On Sale
29
Supersize Everything Part 2
Source Young and Nestle, Am J Public Health ,
2002
30
Obesity How Far Upstream Do You Go?

• Metabolic medical management
• Drugs Coming soon at a theater near you
• Surgery 140,00/year we could be doing 15 million
• The Fat Trapper and Exercise in a Bottle
• Wellness and health promotion
• Public Health Style Prevention
• Reinvigorate participation not competition in
  athletics
• Financial incentives Weighted Premiums or Tax
  BMI
• Urban Design RAND and IFTF
• Tax Policy
• Fat taxes not Flat taxes
• Iowa corn farmers from corn syrup to ethanol
• Fast Food as Tobacco companies
• No subsidy for cars, urban sprawl, commuting,
  drive thrus
• Give all the money to Head Start and public
  school PE

31
Whats the National Game Plan for Financing
Chronic Care?

• Consumer Deflected Healthcare Retail care and
  Catastrophic coverage
• Discounted fee for service everywhere
• Siloed delivery systems
• No incentive for coordination
• No IT infrastructure
• All delivered through a pluralistic Gong Show of
  providers in onesies and twosies intent on
  maximizing their income under the perverse and
  toxic incentives they face
• That should work pretty well, eh?

32
Chronic Care A Long Way to Go
Objective
Source Improving the Care of the Chronically
Ill Is it Good Business? Ed Wagner, MD, MPH.
MacColl Institute for Health Innovation, Group
Health Cooperative, 11/03
Source Chronic Disease Management Through
Quality Improvement the Basics. Chris
Rauscher, MD (Canada), 5/04
33
Across the board, HDHP consumers have more
compliance problems
Treatment compliance problems
Currently insured in employer-sponsored or
self-purchased plan Currently enrolled in high
deductible health plan
34
The Obesity Solution Tiered Fast Food
Formularies

• Sandwiches
• The All Lettuce Whopper Free
• The All Lettuce Whopper with Cheese 15
• Real Whopper with Cheese 35
• Drinks
• Water Free
• Diet Coke 0.99
• Regular Coke 15
• Supersized Regular Coke 35

35
How Can We Impact Costs?
Consumer Corridor Preventive Coverage

• Catastrophic
• DSM
• Pay for performance
• IT (e.g., CPOE, etc.)

36
Who Pays More? Who Benefits?
HC/GDP
Business -
Government
Households
Rx --
Hosps -
MDs - O
Others ?
37
HIT and Chronic Care

• HIT is good thing dont get me wrong
• EMR is a PET
• It wont save money quickly
• Expectations are too high, but
• You gotta spend to save
• You create a platform for improvement
• We do not have another idea
• Strong bi-partisan support conceptually .. Show
  me the money
• The power of simple disease registries what can
  you achieve on 3x5 cards and a telephone
• Enough conferences already, lets get going
• What about the vast rabble of American doctors?

38
Public and Private Players
How big a role should each of the following have
in fighting the obesity epidemic in the US?
Source Lake, Snell, Perry for Harvard Forums on
Health, 2003
39
Health Promotion not Taxation of Fast Food
Would you support or oppose the following as a
way to to fight obesity in the US?
Source Lake, Snell, Perry for Harvard Forums on
Health, 2003
40
Lunch Lady Land Schools Key Role
Would you support or oppose the following to
fight childhood obesity
Source Lake, Snell, Perry for Harvard Forums on
Health, 2003
41
Consider All the Space of Possibilities
Private Issue
Public Issue
Individual
Personal Responsibility
Community
Local Business
Market Response
Corporations
NGOs
State/Local Gov
Federal Gov
Fat taxes