Framing the issue:
• More than one-third of adults and 17 percent of children in the United States are obese.
• Obesity increases the risks of other serious health problems, including heart disease, high blood pressure, diabetes, stroke, several cancers, breathing disorders, osteoporosis and nonalcoholic fatty liver disease.
• Estimates of the medical cost of obesity range from $147 billion to $210 billion a year in the United States.
• Obesity is responsible for $61.8 billion in Medicare and Medicaid spending annually.
• African-Americans have the highest age-adjusted rates of obesity (47.8 percent), followed by Hispanics (42.5 percent), whites (32.6 percent), and Asians (10.8 percent).
With two-thirds of adults and one-third of children in the United States overweight or obese, hospitals need to step up their efforts to prevent and treat the disease.
The STOP (Strategies to Overcome and Prevent) Obesity Alliance came to this conclusion after a year-long project looking at how nonprofit hospitals could address obesity in their communities. “A comprehensive approach is generally not done,” says Scott Kahan, M.D., director of the alliance, a coalition of nearly 70 consumer, provider, government, business and other stakeholder organizations. “The things that we did find were mostly basic prevention programs for kids that some hospitals are engaged in. That’s certainly very valuable. The problem is they’re only really focusing on kids and on prevention.”
The reasons for the dearth of obesity programs are many. They include hospitals’ tendency to focus on the condition’s complications, such as heart disease and diabetes, rather than on the underlying obesity; lack of reimbursement for services; and a shortage of clinicians with obesity training, Kahan says. In addition, obesity only recently has been recognized as a disease, by endocrinologists in 2011 and by the broader medical community in 2013.
However, recent developments could spur more hospitals to address obesity in more depth. One change comes from the Affordable Care Act. It requires nonprofit hospitals to conduct community health needs assessments every three years and to develop implementation strategies to maintain their federal tax-exempt status. Given the prevalence of obesity and the toll it takes on people’s health, community assessments likely will identify the condition as a significant health problem.
Historically, hospitals have tended to stick with community-benefit efforts that concentrate on free indigent care, Kahan says. The hope is that the community assessments will prompt hospitals to think more broadly and use some of their required community-benefit dollars to launch obesity prevention and treatment efforts, he says.
Another development is on the insurance coverage front. “Traditionally, obesity treatment was explicitly excluded from insurance programs,” Kahan says. “There was no incentive for hospitals to provide obesity services because they were not going to get reimbursed for it. That is changing slowly but surely.”
On the upside, Medicare and Medicaid cover bariatric surgery for patients meeting certain criteria. Medicare began covering intensive behavioral counseling, considered a critical component of obesity treatment, in 2011, and the ACA requires most insurers to cover obesity screening and behavioral counseling in some way.
On the downside, 42 percent of large employers and 29 percent of very large employers don’t cover bariatric surgery, according to the 2013 National Survey of Employer-Sponsored Health Plans by the consulting firm Mercer. Also, across insurance types, coverage for nutrition counseling and weight-loss medications is spotty at best.
“Work on the policy level is needed to continue to push reimbursement forward so obesity is treated just like every other health condition with appropriate reimbursement for evidence-based treatments,” Kahan says. “That’s part of what will incentivize hospitals and other types of providers to initiate programs.”
A family focus in Cincinnati
At Cincinnati Children’s Hospital Medical Center, insurers usually pay for most medical services offered to overweight and obese patients, with the exception of nutrition counseling, says Robert M. Siegel, M.D., medical director of the hospital’s Center for Better Health and Nutrition.
The center, housed in the hospital’s Heart Institute, takes a comprehensive, team approach to being overweight and obesity that includes a physician or nurse practitioner, social worker, psychologist, dietitian and exercise physiologist. “We gear it toward what the family members want to do and their readiness to change,” Siegel says. “We work on lifestyle changes for the whole family.”
The focus on lifestyle changes often involves efforts to improve a child’s weight status, but that doesn’t necessarily mean the goal is for the patient to lose weight. “For kids younger than 12 who are still growing, very often we’re trying to keep their weight the same while they grow into it or maybe even just slow their rate of gain.”
Other services for obese children include endocrinology services and lipid, hypertension and fatty liver disease clinics. Patients who are morbidly obese and not getting healthier are referred to the hospital’s surgical weight-loss program.
Cincinnati Children’s also has forged partnerships with more than 20 community organizations to take a broader swipe at obesity. “What we’re hoping to do is put together a comprehensive package that will make for a healthier community with healthful nutrition and healthful activity,” Siegel says.
The hospital underwrites much of its community program’s cost because it helps to support the Heart Institute’s mission to prevent cardiovascular disease.
From schools to the Bengals
As part of the initiative, the hospital is working with local public schools on a pilot project to create an ideal school environment. Cincinnati Children’s has created three school-based medical clinics where overweight and obese children have access to the same services as those in the hospital’s health and nutrition center. The clinics are open twice a month and staffed by a physician, dietitian and exercise expert. The hospital has worked with after-school programs at the pilot sites to ensure that the kids in the program get 30 to 45 minutes of physical activity a day.
The project also features a taste-test program in participating schools’ cafeterias and classrooms. “One of the barriers to healthful eating is that many children are hesitant to eat healthful foods because they literally haven’t tasted the food,” says Monica Mitchell, Cincinnati Children’s senior director of community relations. “It can be a powerful tool to not only recalibrate kids’ palates for healthful eating, but also to create a culture that healthful eating is fun and popular, and kids can actually like foods rather than just say, ‘I don’t like it,’ because they haven’t tried it.”
Locating these efforts at schools removes obstacles to participation, Siegel says. At two of the participating schools more than 95 percent of students are eligible for free lunch. “It’s a very high-risk, vulnerable population, and they have some real barriers to getting into a medical center, even if that’s as close as two or three miles away,” he says. “We’re there to help them and to try to make it as easy for them as possible.”
The long-term goal is to spread programming to all Cincinnati public schools. “We can’t possibly staff clinics at all those schools, but a number of them will have clinics,” Siegel says. “Hopefully, as we get this more and more refined, we’ll spread the cafeteria changes, the after-school changes and the activity changes to all the schools.”
The hospital’s community work includes raising obesity awareness, often by working with partners to develop special events or by having a presence at community events. For example, the hospital collaborates with the Cincinnati Bengals in the National Football League’s Play 60 campaign to encourage kids to be active for 60 minutes a day. More than 600 kids at two schools near the hospital will learn about physical fitness and nutrition, and participate in taste-testing.“
You go where the people are,” Mitchell says. “Often, the people at the most risk for obesity never come through our doors. They’re going to be in schools or out in the community. They might not even know that they have a high body mass index or that their eating habits put them at risk for obesity.” The public awareness efforts reach more than 10,000 children and families each year.
A program in NY targets adults
Adult-centric obesity prevention and treatment programs are uncommon, but some hospitals have developed them.
Syosset (N.Y.) Hospital opened its Center for Weight Management in July 2013. It’s the first of its kind for North Shore-LIJ Health System. “Once we have everything running smoothly here and have the volume, we’ll expand to other locations within the health system,” says the center’s director, Maria Pena, M.D.
The center offers an intensive behavior modification program run by a team of three — a psychologist, a nutritionist and Pena, who recently gained certification as an obesity medicine specialist. Obesity medicine is a new specialty. The first certification test was held in December 2012, and 850 physicians nationwide have been certified.
Patients in the center’s 12-month program first have their BMI measured, and Pena screens them for diabetes, hypertension, cholesterol problems, nutritional deficiencies and presence of inflammatory markers that help to predict heart disease risk. That information is assembled into individual metabolic report cards and is used to drive the patient’s care plan. “These numbers give patients something to quantify as to where they are on the spectrum and motivate them more to lose the weight,” Pena says.
As part of the program, patients have access to an unlimited number of group classes led by a nutritionist and psychologist that give patients tips and techniques about how to change their diets and lifestyles.
Pena reassesses each patient’s metabolic report card at least every three months. The program’s goal is for patients to attain successful medical weight loss, which means shedding 5 to 10 percent of total body weight. “Does that mean you’re going to enter the perfect BMI? Not necessarily, but BMI is just a loose indicator,” Pena says.
Patients who attain that level of weight loss notice an improvement in their overall lifestyle and often are able to stop taking their blood pressure or diabetes medications or at least reduce their dosage. Because the program is so new, no official outcomes data are available, but Pena says the success rate has been good.
The idea that BMI alone isn’t sufficient for determining whether a person is overweight or obese is reflected in a new obesity definition and diagnostic strategy announced by the American Association of Clinical Endocrinologists in May. The reason for the adjustment is that BMI doesn’t indicate how weight gain might be affecting the health of individual patients.
The new approach has four steps: screening using BMI, with adjustments for ethnic differences; clinical evaluation for the presence of obesity-related complications using a checklist; staging for the severity of complications; and selection of prevention or intervention strategies that target specific complications.
A twofold role for hospitals
Obesity screening should be built into hospital stays, suggests J. Michael Gonzalez-Campoy, M.D., medical director and chief executive officer of the Minnesota Center for Obesity, Metabolism and Endocrinology, an independent practice in Eagan. “Almost universally, unless a patient were admitted for bariatric surgery, obesity is not listed as a disease in the dismissal summary despite a hospitalization for obesity-related complications,” Gonzalez-Campoy says. “A plan to address obesity is seldom a part of the discharge planning. So hospitals stand to be major forces in driving obesity care simply by addressing this disease as they would all other diseases.”
Another powerful role hospitals can play is to work to change perceptions about obesity.
The general public and policymakers typically are supportive of using resources for childhood obesity programs, Kahan says. But that’s often not the case when it comes to adults. “People tend to have a very hard time investing in adult obesity initiatives because, unfortunately, they feel that all these people have to do is to eat healthfully, exercise and take care of themselves,” he says. “That’s a very biased and stigmatized view. We don’t say that about people with diabetes and such, even though the same underlying issues that lead to obesity are the things that lead to diabetes and high cholesterol.”
Hospitals can help. “If hospitals are speaking in an appropriate and fair language around obesity — language that is empowering for people and that informs — they can really shift how people think about obesity and, ultimately, how it’s treated in communities,” Kahan says.
— Geri Aston is a contributing writer to H&HN.
The Blue Zones Project inspires an Iowa hospital’s staff
Spencer (Iowa) Hospital has taken a rather unique path to combating obesity and promoting healthful living inside and outside its walls. In 2012, the hospital was the first employer in Iowa to be designated as a Blue Zones worksite.
The Blue Zones Project aims to spread the lifestyle characteristics common in communities around the globe where people reach age 100 at rates 10 times higher than in the United States. Iowa Gov. Terry Branstad launched a statewide Blue Zones initiative in 2011.
To become a Blue Zones worksite, Spencer Hospital had to take steps to create a work atmosphere that promotes and inspires well-being and to engage at least 25 percent of its employees in a personal pledge to well-being.
When the wellness committee looked at the checklist for worksite certification, it realized the hospital already had met many of the criteria, says Candace Daniels, employee benefits and wellness coordinator and co-chair of the town’s Blue Zones worksite committee. “We wanted to challenge ourselves, though, so we created a separate column of things we’re currently doing but could do better.”
The initiative led to some innovative changes, Daniels says. For example, the hospital promotes walking meetings, created a “path” in the basement, and allows employees to get standing workstations if desired when their areas are up for renovation.
Also, the hospital recently rolled out a volunteer campaign called “Giving Back.” The first project was to clean the yards of hospital volunteers and auxiliary. “One woman came out and said, ‘I’ve been volunteering at the hospital for 30 years, and this is one of the best things that has happened to me for doing that,’ ” Daniels says. “It was so fun to give back to them.”
One principle of Blue Zones is joining or creating a moai, based on a Polynesian concept, in which a committed group of friends makes health a priority. “It’s that social piece that keeps people going,” Daniels says. “The volunteer campaign helps to facilitate that; I see my co-workers in a different light because they’re beside me volunteering with their families.” The hospital also has a number of informal walking groups and is in the midst of a challenge for employees to walk 100 miles in 100 days.
The Blue Zones program builds on an effort the hospital had created in 2011 to lower its skyrocketing employee health-benefit costs. The hospital offers a $600 insurance premium incentive for singles and $1,200 a year for employee plus spouse or family if they get screened for metabolic syndrome — a cluster of conditions, including excess abdominal weight, that together increase the risk of heart disease, stroke and diabetes. For employees or spouses who have three or more of the syndrome’s five risk factors, the hospital pays for a 10-week weight-loss program. As of last year, those who continue to have three or more risk factors must eliminate one to get their wellness incentive.
Since 2011, the percentage of insured spouses with three metabolic syndrome risk factors fell from 43 percent to 13 percent, while the percentage of employees with three risk factors dropped from 21 percent to 10 percent. “Our health premiums have literally stabilized,” Daniels says.
As part of the Blue Zones project, Spencer Hospital has been sharing its story with other employers. Local businesses now request metabolic screenings for their employees, and the local utility company has adopted the hospital’s approach of metabolic syndrome screening and paying for the weight-loss program.
“It’s just great to see pieces of our wellness initiative spilling out and being mirrored in the public,” Daniels says.
The STOP Obesity Alliance offers a number of considerations and suggestions for nonprofit hospitals that choose to address obesity as part of their community benefit programs in its report, “Community Benefit and Obesity Programming: Guidance and Opportunities for Nonprofit Hospitals.”
• The Internal Revenue Service allows hospitals to report spending on programs in which the hospital is an active participant in providing the community benefit services, as well as funding and in-kind contributions to other organizations providing the services.
•Before embarking on an obesity initiative, hospitals should determine whether a project already exists in their community and, if so, whether it makes more sense to partner with that organization or to create a new program that targets a different population or offers a different intervention.
•Community needs assessment results can help hospitals to identify populations in most need of obesity programs. Target groups could be children, adults, minorities, low-income residents or the community at large. Many communities lack programs geared toward adults or families.
•To achieve the greatest impact within the community and to leverage resources, hospitals probably will want to partner with outside community organizations to help plan, administer and participate in day-to-day operations of their local obesity programs. The availability and expertise of local organizations and the program’s target population will help to determine appropriate partners.
•Community benefit programs may include clinical services, but other types of initiatives to combat obesity also count. Interventions can include efforts to make communities more walkable or to increase access to nutritious foods or exercise facilities.