Editor's note: John Bluford, president and CEO of Truman Medical Centers in Kansas City, Mo. and immediate past chairman of the American Hospital Association, is guest blogging today.
When you journey to the safety net hospitals and clinics that serve some of the neediest Americans, you will invariably find yourself in the heart of the urban core.
Nearby you will see establishments such as liquor stores, convenience stores and fast food restaurants. But more significant is what you typically will not see: grocery stores that offer a wide variety of healthy foods at affordable prices.
This is certainly the case at the urban core campus of Truman Medical Centers in Kansas City, MO., where I am the president and CEO. TMC is one of the most crucial safety net hospitals in the Kansas City area, providing services to more than 56,000 medical home patients with chronic diseases like diabetes, congestive heart failure, hypertension and obesity.
Yet while my office is about a minute away from a purveyor of cheeseburgers and fries, it is quite a distance from the closest fresh produce case. In other words, my hospital stands in the midst of an urban core "food desert."
The lack of healthy grocery shopping alternatives in Kansas City's urban core is illustrated by a Healthy Food Access Map published in June 2011 by the Mid-America Regional Council.
Most of us enjoy a hot, juicy cheeseburger and a bag of crunchy fries now and then. But the preponderance of such food in the urban core, along with the dearth of healthy, affordable food, is a major cause of obesity and chronic health conditions.
This link between fast food, bad nutrition and chronic illness impacts TMC every day, as we are fast becoming experts in the management of chronic disease. In our last fiscal year, 56,426 of the 96,644 unduplicated patients we served had at least one of the seven most common chronic illnesses.
Out of those 56,426 patients who had at least one chronic illness, 13,488 were diabetic patients, 4,128 were obese (main health concern) and 24,328 suffered from hypertension. So nearly three-quarters of the chronic illness patients we served last year suffered from a condition in which poor nutrition can adversely affect their disease management.
In addition, more than 4,000 patients visit the TMC Diabetes Center every year. We are well equipped to handle all aspects of the disease, but it would be so much better for patients if they could avoid diabetes in the first place through better nutrition.
Obesity's Heavy Toll
The preponderance of junk food in the cores of American cities is part of a larger problem that plagues Americans across the socioeconomic spectrum: obesity.
The impact of this plague has been documented in study after study. One such report is "Reducing Obesity: Policy Strategies from the Tobacco Wars," which was released in 2009 by Carolyn L. Engelhard and Arthur Garson Jr. of the University of Virginia Stan Dorn Urban Institute.
Engelhard and Garson cited a 2008 Congressional Budget Office report that said per capita health care spending rises by 34 percent when an individual is obese and by 70 percent when an individual is morbidly obese. More than one-quarter of increased medical costs between 1987 and 2001 involved obesity-related expenditures, the report noted.
"Put simply, obesity is one of the country's gravest public health problems," the Engelhard-Garson report states. "For each affected individual, it has a significantly greater effect on health status and health spending than either tobacco use or heavy consumption of alcohol. Obesity causes death and illness on a massive scale and generates enormous costs for employers, taxpayers, workers and the health care system as a whole. Unless effective interventions are devised, this is projected to grow much worse over time."
According to the Mid-America Coalition on Health Care, of which TMC is a member, approximately 9.1 percent of all health care costs in the United States are related to obesity and being overweight.
That is a mind-boggling percentage when you consider that U.S. health care costs reached $2.5 trillion in 2009. Even more mind-boggling is the estimate from Health & Human Services that growth in health care spending will average 6.1 percent per year between 2009 and 2019. And this at a time when federal and state agencies are wrestling with health care spending cuts that could severely impact our neediest citizens.
The Mid-America Coalition on Health Care report notes that approximately two-thirds of U.S. adults with Type 2 diabetes are obese, and that the national cost of diabetes in 2007 was more than $174 billion, including $116 billion in excess medical expenditures. In addition, 14 to 20 percent of cancer deaths in the United States can be attributed to excess weight or obesity-associated issues, the Coalition report notes.
The Kansas City Health Department has documented the connection between obesity and cardiovascular disease, asthma and diabetes.
Indeed, the burdens of physical inactivity and poor diet represent some of the most significant threats to public health in the United States, according to Building a Healthier Heartland, a public-private collaboration working to improve health in the Kansas City area.
BHH reports that the prevalence of obesity more than doubled from 13.3 percent in the 1960s to 32.1 percent in 2004, and that medical spending averages $1,400 more per year for an obese person than for someone of normal weight. Widespread efforts for several generations have not significantly impacted these health risks. I agree with BHH's conclusion that new approaches are needed.
The impact of obesity extends beyond direct health care outlays. The Mid-America Coalition on Health Care report states that additional estimated costs of obesity include $4.3 billion a year in worker absenteeism and lower productivity that amounts to $506 per worker per year.
So why has obesity become so much more prevalent? In a 2011 report on obesity, the Kansas City Health Department stated that "the rise in obesity rates is a result in changes in the environment that have simultaneously lowered the cost of food production, lowered the time and monetary cost of food consumption, increased the real cost of being physically active at work and at home, and decreased the health consequences that result from obesity by bringing a host of new drugs and devices to the market to better manage the adverse effects that obesity promotes."
The highest rates of obesity and diabetes are among people who live in lower-income communities and have worse food environments, according to "Designed for Disease: The Link Between Local Food Environments and Obesity and Diabetes," a 2008 report published by the Regents of the University of California, PolicyLink and the California Center for Public Health Advocacy.
"However, for people living in lower-income and higher-income communities alike, the higher the ratio of fast-food restaurants and convenience stores to grocery stores and produce vendors near home, the higher the prevalence of obesity and diabetes," the "Designed for Disease" report stated.
Junk Food is Not Cheaper
Some may argue that it is not realistic to expect financially strapped urban core dwellers to eat healthy food. Those who espouse this point of view frequently say that fast food, junk food or whatever you wish to call it is simply cheaper and represents the best food value attainable in the hearts of our cities.
It would be quite sad if that position were true. Fortunately, it is false. And all you need to do to expose that falsity is to compare the cost of a fast food meal with the cost of a home-cooked meal that's prepared with healthy food bought at an average grocery store.
The numbers underlying this debate were laid out succinctly in a Sept. 24, 2011 article in the New York Times by Mark Bittman, a well-known food journalist. Bittman wrote that a typical order for a family of four at a McDonald's near his writing desk runs about $28. That's the tab for two Big Macs, a cheeseburger, six chicken McNuggets, two medium and two small fries, and two medium and two small sodas.
By comparison, Bittman wrote, for $14 you can serve a home-cooked meal of roast chicken that would feed four to six people. Or for only $9 you can dish out a meal of rice and canned beans with bacon, green peppers and onions, Bittman added.
A Call to Action
Donald W. Zeigler, Ph.D., director of prevention and healthy lifestyles for the American Medical Association, took McDonald's to task at its May 19 annual shareholders' meeting in Chicago.
Zeigler said he took the podium as a concerned health professional, "because today our doctor's offices, pediatric clinics and hospitals are crowded with patients suffering from conditions related to the food they eat. We face what the World Health Organization calls a slow-motion catastrophe of non-communicable diet-related diseases, such as obesity, diabetes and cardiovascular disease, linked to the promotion and consumption of fats, sodium and sugars that are ubiquitous in fast foods."
He noted that in its action plan to reverse this trend, WHO recommends enacting policies to reduce fast food and junk food marketing to children. Ziegler said that is why he had joined more than 550 health professionals and institutions to "call on McDonald's to retire Ronald and its marketing of junk food aimed at children."
Of course, it will take more than Ronald McDonald's retirement to loosen the hold of fast food on the American palate and psyche. In his New York Times article, Bittman cited a 2009 study by the Scripps Research Institute that indicates that overconsumption of fast food "triggers addiction-like neuroaddictive responses" in the brain that make it harder to trigger the release of dopamine.
"In other words, the more fast food we eat, the more we need to give us pleasure," Bittman wrote.
I agree with Bittman's assertion that "real cultural changes are needed to turn this around," such as "no-nonsense cooking" becoming popular again. That might sound like an awfully tall order for a nation where fast food is so pervasive. But it can and must be done.
There are many ways we can make a difference. The Mid-America Coalition on Health Care's Gateway Project for Worksite Interventions to Improve Hypertension Management points out that "eating a healthy diet, maintaining a healthy weight and staying physically active can help prevent high blood pressure."
On an individual level, people need to re-prioritize their schedules and carve out more time to buy and prepare nutritious food — for themselves, and for their children and grandchildren.
Schools must ban junk food from their campuses and companies must offer healthy alternatives in the corporate cafeteria.
Many organizations are joining in the fight. Among them is the Greater Kansas City Food Policy Coalition, which strives to attain a healthy, sustainable and affordable food system for our community.
Building a Healthier Heartland partners recognize that tackling America's health risks requires cross-cutting strategies that incorporate evidence-based changes promoting physical activity and healthy eating into the health and wellness programs of work sites, faith-based organizations, neighborhoods and school communities. No partner can do it alone, and BHH offers a "super-coalition" opportunity to maximize the reach, impact and shared lessons learned of strategies that work to address obesity.
Clearly, a multipronged approach is needed. A 2005 PolicyLink study entitled "Healthy Food, Healthy Communities: Improving Access and Opportunities through Food Retailing," had this to say:
"New grocery stores can locate in poor communities and spur economic development. Existing small stores can stock healthier options, promoting local small business development, and in some cases turning a place seen as a community problem into an asset. Farmers' markets can help sustain small farmers while providing fresh food for residents, opportunities for small business development, and a public space for increased social interaction. Residents can benefit from a renewed sense that they live in a vibrant, healthy community."
A Kansas City municipal report entitled "Active Living & Healthy Eating Development Code Review" recommends the identification of "potential incentives for developers who build healthy food stores (and) grocery stores," or "set aside land or space for a farmer's market or community garden."
We hospitals must do our share also. This amounts to enlightened self-interest on our part. Naturally, we want to lower our cost of uncompensated care. But at the same time, achieving better health status through better nutrition is a goal that ties in to our mission of healing.
At TMC, we are seeking to replace the fast food restaurant at our urban core campus with a vendor that will offer healthier food. I feel very strongly about this, because I don't think our message about healthy eating will resonate unless we set a good example.
TMC also is working toward the establishment of a new grocery store near our campus that will offer healthy food at prices our neighbors can afford. By doing so, it is my hope that we will create an oasis in our food desert.
Each one of us has a role to play, and each one of us must do his or her part in this fight. The health of our communities depends on it.