Posts Tagged ‘taxes’

Note to Mayor Bloomberg: It’s Harder than you think

September 27th, 2012

On September 13, 2012, the New York City Board of Health enacted Mayor Michael Bloomberg’s proposal to limit the size of cups selling soda in New York City. The soda cup size ban over 16 oz only for facilities subject to inspection: restaurants, movie theatres, and stadium concession stands. Not covered are convenience stands, including 7-Elelven’s  (and its king-size Big Gulp drinks), vending machines and some newsstands. Also not affected are fruit juices, dairy-based  drinks like milkshakes or alcoholic beverages and non-caloric beverages. Fast food restaurants with self-service drink fountains would not be allowed to stock cups larger than 16 ounces. http://www.nytimes.com/2012/09/14/nyregion/health-board-approves-bloombergs-soda-ban.html.

There is no ban on  buying  two under 16oz cups of soda, selling ‘two for the price of one’, or free re-fills.

While most anti-obesity advocates shudder at the thought of sugar sweetened beverages, there is doubt over whether a ban on the size of the cup in which they are delivered is going to have much impact. Here’s why.

  1. Most sugar sweetened beverages (SSBs) are consumed by teenage boys, especially low income African-American and Hispanic. The ban rests on a hope that the consumers will voluntary switch from SSBs to some non- or low-caloric beverage. Yet, there is no educational campaign or subsidy to get them to substitute an SSB for another no/low-calorie drink. http://www.cdc.gov/nchs/data/databriefs/db71.pdf
  2. Males consume an average of 178 kcal from ssbs on any given day. Among males 12-19, consumption is highest at 273 kcal a day. This is still only a small  fraction of their total daily caloric intake. http://www.cdc.gov/nchs/data/databriefs/db71.pdf

At 273 kcal a day, a person would put on about 28 pounds a year. This is not happening, so the caloric intake is probably balanced to a large, if not full extent, by energy expenditure. The CARDIA study of 18-30 African-American and white men  and women   found that physical fitness changes were most strongly associated with weight changes over 7 years. Weight changes in this study range from 5.2kg in white women to 8.5 in African-American women.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1380845/pdf/amjph00503-0109.pdf

  1. Over half of sugar drink kilocalories, 52%, are consumed in the home, 92% having been purchased in stores. Presumably, the store-bought items are in cans and bottles, not in the cup sizes subject to the NYC ban. Of the 48% of kcal consumed away from home, 35.5% are purchased in fast-food restaurants and 1.4% in schools or daycare settings. 20% are consumed in vending machines, cafeterias, street vendors and community food programs. So, only about 1/3 of sugar drink consumption is in restaurants or fast-food outlets.   http://www.cdc.gov/nchs/data/databriefs/db71.pdf
  1. SSBs, while associated with increased daily caloric intake, are not the leading source. According to Harvard researchers Frank Hu and colleagues, the components most associated with increased intake are potato chips (1.69 lbs), potatoes (1.28 lbs), SSBs, (1 lb) unprocessed red meats (0.95 lb) and processed meats (0.93 lb), in that order. http://www.ncbi.nlm.nih.gov/pubmed/21696306.
  1. African-Americans need many changes to diet to affect CVD risk factors, including additional whole grains, vegetables and fish intake, reduction in saturated fat, sodium as well as sugar according to study by Carson et al in September 2012 Journal of the Academy of Nutrition and Dietetics. PubMed: Cardiovascular Health of Urban African Americans (I think this applies to all of us.)
  1. The most influential factor driving childhood obesity is parental weight, especially that of the mother, independent of the effect of socio-economic status. See Causes of Obesity also, http://www.ncbi.nlm.nih.gov/pubmed/19165162 A new study from Elmear Keane and  colleagues in Ireland provides further support for this. PubMed: Measured weight status and familial SES

To look at the combination of genetic pre-disposition to obesity and in the intake of SSBs, Qibin Qi  and colleagues at Harvard School of Public Health looked  at 32 genetic loci (called “risk alleles”) known to be associated with BMI.  They grouped the 32 loci into 3 groups and looked at prospective 4 year beverage intake data from two large studies. Participants who were obese at baseline were excluded.  They found a rising BMI from greater intake of SSBs. For every 10 risk alleles, the increases for BMI was 1.0 for one serving a month, 1.2 for one to four servings per week, and 1.85 for one or more servings per day. In a sub-analysis,  they excluded the FTO gene, known for its impact on body weight, and found similar results. They concluded that “persons with a greater genetic predisposition to obesity appeared to be more susceptible to the deleterious effects of sugar –sweetened beverages on BMI. PubMed: Sugar-Sweetened beverages and Genetic Risk of Obesity The implication of this article is that NYC may have overreached…applying a rule to all when only some are most affected.

Two intervention studies were published in the New England Journal of Medicine, along with the study above.  One, by Cara Ebbeling and colleagues, divided 224 overweight and obese adolescents into 2 groups. The first group received home delivery of non-caloric beverages and were followed for another year. The second group acted as controls. Consumption of SSBs in the first group declined significantly but at the end of 2 years there was not difference in BMI between the two groups.PubMed: Randomized Trial of SSB and Adolescent Weight

The other intervention study, by de Ruyter and colleagues, had a larger sample size (641 normal weight children from 4 yrs 10 months to 11 yrs 11 months) and was a double blind model.  Half received a sugar-free non-carbonated beverage and the other have a sugared non-carbonated drink.  26% dropped out of the study. If this were an obesity drug study, a great deal would be made of this. Evidently they dropped out because they no longer liked the taste of the beverage. The researchers assume they went back to consuming sugared beverages. They found that “masked” replacement of the SSB by a sugar-free beverage significantly reduced weight gain and fat accumulation in normal weight children. The difference was 1.01kg. However, the authors calculate that approximately 0.8kg of the differences in weight gain was due to fat mas and associated muscle and other tissues.  PubMed: Trial of sugar-free or sugar-sweetened beverages

You can listen to David Allison discuss the SSB issue and these studies at http://themixuab.blogspot.com/2012/09/do-sugar-sweetened-drinks-drive-obesity.html.

These studies were published in the New England Journal of Medicine September 21, 2012 edition.  Mayor Bloomberg could have looked at other recently published studies to see the difficulty of regulating consumption of SSBs.

Levy et al looked at school nutrition policies and price interventions directed at youth consumption of sugar sweetened beverages (SSBs). They found that school nutrition and price policies reduce SSB consumption and that reduced SSB consumption is associated with a reduction in energy intake that “can” influence Body Mass Index Their review of the literature found that the effects of nutrition policies on BMI were less conclusive, possibly due to the lack of adequate follow-up period or that reduced SSB consumption in school is compensated for by increased SSB consumption outside of schools. The authors’ concluded that, “The reduction in energy intake from even just one 8-oz serving of SSB appears enough to have important effects on the prevalence of overweight and obese youth if policies are started at early ages and maintained.”  PubMed: Review of the literature on policies youth consumption of SSB

Of course, the key word here is “if.” Some of the calculations of the benefits of reducing or eliminating SSBs, are premised on the assumption that the calories contained in SSB will not be compensated for by other caloric intake. PubMed: Effect of school district policy change on consumption of sugar An analysis of SSB consumption in middle schools compared students in states which reduced access and purchase with those that did not. The main finding was that SSB consumption was not associated with state policy, i.e. in-school access is reduced but overall consumption is not changed. PubMed: Banning all sugar-sweetened beverages in middle schools A study by Wang et al, calculated what a penny-per-ounce tax on SSBs would mean for health care costs and diabetes. They calculated that 40% of the calories in SSB would be replaced by other caloric intake and 60% of SSB calories would not be replaced. This would translate to a mean reduction of 0.9 pound in mean at the population level, with a greater impact on younger adults, a 1.5% reduction in the number of adults with obesity. This decline would further translate into a reduction of new cases of diabetes by 2.6% and cost savings over ten years of $17.1 billion. PubMed: Penny-per-ounce tax on sugar-sweetened beverages. However, the 40%-60% split was only an estimate, it wasn’t based on experimental or real world results.

News reports indicate 24 states and 5 localities which proposed taxes on sugar sweetened beverages failed in their attempts over the past 2 years. Industry resistance to taxes and regulation has been strong and effective. ( Reuters: Special Report: How Washington went soft on childhood obesity http://www.reuters.com/article/2012/04/27/us-usa-foodlobby-idUSBRE83Q0ED20120427, accessed April 28, 2012)

Worldwide, some 20 countries have banned all sugar-sweetened beverages from schools and about 12 have banned 100% fruit juice as well, according to Barry Popkin and colleagues. PubMed: Global Nutrition Transiiton and the Pandemic of  Obesity Hawkes and colleagues have found that 26 countries have made explicit statements on food marketing to children and 20 or so are developing explicit policies in the form of statutory guidelines or approved forms of self-regulation. PubMed: Regulationg the commercial promotion of food to children

Denmark last year became the first nation to tax sugar but has since rescinded its tax because it was hurting domestic businesses while Romania has introduced a lower value-added-tax on staple foods. New Zealand is researching taxing foods with little or no nutritional value at higher rates than more nutritious foods. Professor Sir Nicholas Wald, director of the Wolfson Institute of Preventive Medicine has proposed an all-embracing SASS (salt, sugar, alcohol and saturated fat) tax.  PubMed: Is a tax on junk food moving closer?

One alternative approach is to tax all SSB sales, whether in school or out of school. Researchers have pointed out that, in 2007, 34 states taxed soda sold in grocery stores and 39 taxed soda sold in vending machines at mean rates of 3.4% and 4.0% respectively. The tax was never greater than 10% of the price.  Several studies are cited which showed no effect on BMI from such taxes. PubMed: A review of the literature directed at the youth consumption of SSB Sturm et al point out the greater benefit of larger tax than a smaller tax to affect behavior. PubMed: Soda taxes, soft drink consumption, and children’s body mass index.

For an excellent discussion of food taxes, see these presentations from University College, Dublin.

The New York City experiment will be tested in court and then it will be tested in practice to see if it actually has an effect on reducing weight gain or causing weight loss. But there are other public policy options worth exploring. Mayor Bloomberg also proposed a waiver for the city from the Department of Agriculture to allow restrictions on the purchase of certain foods by families with SNAP benefits. SNAP is the Supplemental Nutrition Program for Women, Infants and Children. SNAP is a federal program designed to reduce hunger and food insecurity among low-income Americans.  In a study using store scanner data, Tatiana Andreyeva and colleagues at the Rudd Center for Food Policy and Obesity  looked at patterns in the New England states. They found on average that SNAP households purchased 689 oz of beverages per month, including 399 oz or 58% of SSBs. The researchers estimated that SNAP spends annually between $1.713 billion to $2.05 billion on SSBs. They note that no-calorie beverages and water were equally available and no more expensive. SNAP households appear to obtain more total energy from SSBs than the general, higher-income population. PubMed: Grocery Store Beverage Choices by Participants in Federal food

So there are other public policy options. But this debate over SSBs show the problem with over-simplifying obesity to one source, fashioning a simplistic response, only to see the “solutions” fail. This stuff is difficult and we need to appreciate how difficult it truly is.

 

Employer Incentives

September 27th, 2009

Employer Wellness Programs

In recent years, employers, mainly large ones, have developed wellness programs designed to promote healthier lifestyles among their employees while at the same time reducing their health care expenses. Recently, questions have arisen addressing how much of an incentive can an employer provide before it becomes a punitive measure. The National Business Group on Health has proposed as part of health care reform that the tax code be amended so that the expense of the employer-sponsored program is not taxed as income to the employee when provided off-site. Likewise, employees would be able to use their own health spending accounts for fitness and weight management.

Others have sought to change current laws to allow employers to provide significant financial rewards to persons with certain conditions under control or, from the other viewpoint, penalize workers who cannot bring such conditions, under control.

New research from the National Bureau for Economic Research indicates that financial rewards for weight loss simply do not work. Outcomes in a Program that Offers Financial Rewards for Weight Loss

Safeway, for example, has been promoting their plan called Health Measures. This plan gives employees reduction in their insurance premiums if they are, and stay, within certain limits on four medical risk factors: smoking, obesity, blood pressure and cholesterol. Rebates for achieving the goals total nearly $800 for an employee or $1,600 for a family. People who test within the limits get lower health premiums at the outset of the year. An employee who fails the obesity test can get a retroactive payment if he or she loses 10% of his or her body weight by the end of the year. But if the person’s BMI is still over 30 at the beginning of the following year, the payment is withheld until the employee reaches the permanent goal of under a BMI of 30. (See, Bensinger Gail, Corporate Wellness, Safeway style, http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2009/01/02/CM1714IPV8.DTL&type=health, accessed May 24, 2009)

Legally, the Safeway program may be pushing the envelope. Under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), no person can be denied or charged more for coverage than other similarly situated person (e.g. full time, part time) because of health status, genetic history, evidence of insurability, disability or claims experience. HIPPA “makes it easy for health plans to reward members for participating in health-promotion programs but difficult to reward them for achieving a particular health standard, “ according to Mello and Rosenthal. In one allowable category for wellness programs, employee rewards are based solely on participation. The second category allows rewards based on attainment of a specific standard, such as losing a specific amount of weight, but the financial incentive is limited to less that 20% of the cost of the employee’s coverage. If the person cannot meet the standard if it is unreasonably difficult or medically inadvisable, that person must be offered a reasonable alternative standard. Other federal and state laws also apply to this situation. (Mello MM, Rosenthal MB, Wellness Programs and Lifestyle Discrimination – The Legal Limits, NEJM July 10, 2008; 359: 192-199) Wellness programs and lifestyle discrimination–th…[N Engl J Med. 2008] – PubMed Result

Safeway President Steven Burd has called for overturning the HIPPA 20% rule and the provisions of the Americans with Disabilities Act which prevent companies from being more aggressive about pushing employees reaching specific personal targets.

This is a highly sensitive issue for several reasons:

  1. Obesity is caused by a multitude of factors a few of which are under an individual’s control. By the time a person enters the workforce, the number of fat cells (adipose tissue) has been established and will not change no matter what the intervention, including bariatric surgery. Genetic predisposition and an environment overwhelming favoring the easy availability of food are two extremely strong factors for an individual to try to overcome. Eating and exercise habits are ingrained. It is therefore of some concern that the person who designed the Safeway program, Ken Shaclmut, Senior VP for Strategic Initiatives, indicated, “I want to be clear – we were adamant about designing this program to cover only those things for which our employees had control and which were clearly behavioral in nature. We do not differentiate for genetics and we did everything prospectively and transparently so that everyone had equal opportunity to improve their behaviors.” ( Emphasis added. http://www.thehealthcareblog.com/the_health_care_blog/2008/10/safeway-uses-in.html Accessed May 24, 2009).

A few things about this statement. First, obesity has a strong genetic basis. See, Understanding Obesity.

Second, Mr. Shaclmut may overstate the level of individual control over the three other factors – smoking, blood pressure and cholesterol. What makes these risks controllable has little to do with behavior and more to do with a variety of prescription and over-the-counter drugs for their control. Obesity is, unfortunately, lacking the number and variety of such products.

Three, employers already discriminate against persons with obesity in firing, promotion and hiring decisions. A recent paper addressed 32 experimental studies in weight discrimination in employment. The findings demonstrated that overweight and obese individuals are disadvantaged in workplace interactions, evaluations, and employment outcomes as a result of negative weight stereotypes. (Roehling MV, Pilcher S, Oswald F, Bruce T, The effects of weight bias on job-related outcomes: a meta-analysis of experimental studies. Academy of Management Annual Meeting, Anahiem, CA, 2008 )

Fourth, another recent study for the negative association between BMI and wages is larger in occupations requiring interpersonal skills with presumably more social interactions. This wage penalty increases as employees get older. This study demonstrates that being overweight and obese penalizes the probability of employment across all race and gender groups except for black men and women. (Han E, Norton ED, Stearns SC, Weight and Wages: Fat Versus Lean Paychecks, Health Econ 2009; 18:535-548 Weight and wages: fat versus lean paychecks. [Health Econ. 2009] – PubMed Result)

Fifth, obese employees in firms which provide employer paid health care are paid less than their peers for the same work. This indicates that employers are offsetting the higher health care costs of obese employees with lower wages. Bundorf MK, Bhattacharya J. The Incidence of the Health Care Costs of Obesity, Abstr AcademyHealth Meeting 2004;21: No. 1329. Available at www.nber.org/papers/w11303 – 17k – 2005-05-02)

Sixth, the difficulties of weight loss and maintenance of weight loss need to be understood. About 1/3 of American adults are engaged in weight loss efforts at any given time. Yet, obesity increases. Why is that? Some dieters do succeed in weight loss but few, 5-10%, manage to keep the weight off over the long term. (See, Freedman MR, King J, Kennedy E, Popular Diets: A Scientific Review. 2001, Obesity Res. 9 Suppl.1: 1S-40S. Popular diets: a scientific review. [Obes Res. 2001] – PubMed Result Maintaining weight loss is extremely difficult. As soon as weight starts to decrease, energy expenditure also drops in obese individuals. Not only is resting metabolic rate decreased; non-resting energy expenditure is also less because less mass is being moved. Take the situation with persons with type 2 diabetes, a common chronic disease highly correlated with obesity. Weight loss in this population is very difficult. Typically, patients lose weight over 4-6 months then plateau. Patients generally lose about 4-10% of their baseline weight. Hypothalamic signals in defense of body weight increase and intervene to prevent further weight loss. This initiates a regain of the lost weight. Neurotransmitters are activated to such an extent that the signal levels of increased hunger and decreased satiety become extremely difficult to ignore. Also, most diabetic patients are on anti-diabetes medications, many of which, like insulin, actually cause weight gain. (See, Pi-Sunyer, FX, Weight Loss in Type 2 Diabetic Patients, Diabetes Care, June 2005, 28;6:1526-7 Weight loss in type 2 diabetic patients. [Diabetes Care. 2005] – PubMed Result )

Seventh, employer wellness programs, as they apply to obesity, are not precisely defined. At present they encompass a variety of approaches and do not have a standardized format. It does appear that they provide advice on nutrition and physical activity and perhaps the ill effects of obesity. As such, they would be similar to the behavioral format used as standard therapy for control groups in randomized clinical trials, usually of pharmacological compounds. Such interventions have not been particularly effective. (See, Poston WS, Haddock CK, Lifestyle Treatments in Randomized Clinical Trials of Pharmacotherapies for Obesity. Obesity Research 2001 9;9:552-563. Lifestyle treatments in randomized clinical trials…[Obes Res. 2001] – PubMed Result) However structured, it is impossible to think that an employer wellness program would be as intense and well-funded as the Diabetes Prevention Program (DPP). In this study over 3,000 non-diabetic persons with elevated fasting and plasma glucose concentrations ( but not diabetes) were assigned to placebo, metformin (a drug to treat diabetes) or an intensive life-style modification program with the goal of at least a 7% weight loss and at least 150 minutes of physical activity per week. “The lifestyle modification intervention reduced the incidence of diabetes by 58% compared to 31% in the metformin group. The advantage of lifestyle intervention over metformin was greater in older persons and those with a lower body-mass index than in younger persons and those with higher body-mass index.” The weight loss difference between the lifestyle group and the metformin group was barely 4 pounds after 4 years. Only 10 million persons in the United States resemble the participants in the DPP. (Diabetes Prevention Program Research Group, Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin, New England Journal of Medicine, 2/7/2002 346:393-403. Reduction in the incidence of type 2 diabetes with…[N Engl J Med. 2002] – PubMed Result)

Eight, employer wellness programs do have adequate evidence of their effectiveness at long term weight loss and maintenance. A CDC Report evaluating such programs reported, “The Task Force determined that insufficient evidence existed to determine the effectiveness of single-component worksite interventions focused on nutrition, physical activity, or other behavioral interventions among adults.” (Katz DL, et al, Public Health Strategies for Preventing and Controlling Overweight and Obesity in School and Worksite Settings, A Report on Recommendations of the Task Force on Community Preventive Services, MMWR, Oct. 7, 2005 Public health strategies for preventing and contro…[MMWR Recomm Rep. 2005] – PubMed Result) More recently, Goetzel and Ozminkowski looked at the health and cost benefits of work site health-promotion programs. Commenting on a 2007 systematic literature review they observed, “Health and productivity outcomes from these interventions were reported from 50 studies qualifying for inclusion in the review. The outcomes included a range of health behaviors, physiologic measurements, and productivity indicators linked to changes in health status. Although many of the changes in these outcomes were small when measured at an individual level, such changes when measured at an individual level were considered substantial.” 38 38 (Goetzel RZ, Ozminkowski RJ, The Health and Cost Benefits of Work Site Health-Promotion Programs. Annu. Rev. Public Health 2008;29:303-23 The health and cost benefits of work site health-p…[Annu Rev Public Health. 2008] – PubMed Result)

Ninth, wellnessand prevention programs also may actually be working at cross purposes. It is not uncommon to see programs stress smoking cessation and weight loss. Rarely, however, do they seem to address the perception that smoking cessation will lead to weight gain. A 1991 study by the Centers for Disease Control published in the New England Journal of Medicine found mean weight gain after smoking cessation was 2.8 kg for men and 3.8 for women. Major weight gain of over 13kg occurred in 9.8% of the men and 13.4% of the women. (Williamson DF, Madans J, Anda RF, Smoking Cessation and severity of weight gain in a national cohort. NEJM, 1991 Mar.14;324 (11):739-45. Smoking cessation and severity of weight gain in a…[N Engl J Med. 1991] – PubMed Result) Smoking creates insulin resistance and is associated with central fat accumulation. As a result, smoking increases the risk of the metabolic syndrome and type 2 diabetes. ( Chiolero A, Consequences of smoking for body weight, body fat …[Am J Clin Nutr. 2008] – PubMed Result ) Weight control advice was not associated with reduction in weight gain after cessation. (See, Parsons AC, Shraim M, Inglis J, Interventions for prevention weight gain after smoking cessation. Cochrane Database Syst. Rev. 2009 Jan. 21;(1):CD006219 Interventions for preventing weight gain after smo…[Cochrane Database Syst Rev. 2009] – PubMed Result

Tenth, to the extent that wellness programs which shift costs to employees create stress, they may actually lead to weight gain. We know that chronic stress is a contributor to obesity and the metabolic syndrome. (See, Kyroou I, Tsigos C Chronic stress, visceral obesity and gonadal dysfunction, Hormones 2008 7(4):287-293. Chronic stress, visceral obesity and gonadal dysfu…[Hormones (Athens). 2008 Oct-Dec] – PubMed Result) Overweight women experience more stressful lives events than normal women. Obese and extremely obese men and women are more likely to report several specific stressful life events and more stressful life events overall compared to normal weight individuals. ( See, Gender differences in associations between stressf…[Prev Med. 2008] – PubMed Result

Twelfth, more punitive employer wellness programs are likely to operate like a tax on overweight employees. Compliance with any weight loss regimen involves both time and money. While employers may bear some of this in their programs, the economic burden is likely to fall mainly on overweight/ obese employees, who have already paid a penalty in their wages for their largely inherited status.

Successful maintainers who have lost at least 30 lbs. for an average of five years expended and average of 1.5 hours a day on exercise and consume less that 1,400-1, 500 calories. (See, Klem, ML, Wing RR, McGuire MT, Seagle HM, Hill JO, A descriptive study of individuals successful at long-term maintenance of substantial weight loss. 1997 Am J Clin Nutr 66;239-246 A descriptive study of individuals successful at l…[Am J Clin Nutr. 1997] – PubMed Result))

A recent collaborative position paper explains the issues of money, place and time stated:

The Role of Money

One hypothesis linking SES variables and childhood obesity is the low cost of widely available energy-dense but nutrient-poor foods. Fast foods, snacks, and soft drinks have all been linked to rising obesity prevalence among children and youth. Fast food consumption, in particular, has been associated with energy-dense diets and to higher energy intake overall. Calorie for calorie, refined grains, added sugars and fats provide inexpensive dietary energy, while more nutrient-dense foods cost more, and the price disparity between the low-nutrient, high-calorie foods and healthier food options continues to grow. Whereas fats and sweets cost only 30% more than 20 years ago, the cost of fresh produce has increased more than 100%. More recent studies in Seattle supermarkets showed that the lowest energy density foods (mostly fresh vegetables and fruit) increased in price by almost 20% over 2 years, whereas the price of energy-dense foods high in sugar and fat remained constant.

Lower cost foods make up a greater proportion of the diet of lower income persons. In U.S. Department of Agriculture (USDA) studies, female recipients of food assistance had more energy-dense diets, consumed fewer vegetables and fruit, and were more likely to be obese. Healthy Eating Index scores are inversely associated with body weight and positively associated with education and income .

The Importance of Place

Knowing the child’s place of residence can provide additional insight into the complex relationships between social and economic resources and obesity prevalence. Area-based SES measures, including poverty levels, property taxes and house values, provide a more objective way to assess the wealth or the relative deprivation of a neighborhood. All these factors affect access to healthy foods and opportunities for physical activity.

Living in high-poverty areas has been associated with higher prevalence of obesity and diabetes in adults, even after controlling for individual education, occupation, and income. In the Harvard Geocoding Study, census tract poverty was a more powerful predictor of health outcomes than was race/ethnicity. Childhood obesity prevalence also varies by geographic location. The California Fitnessgram data showed that higher prevalence of childhood obesity was observed in lower income legislative districts. In Los Angeles, obesity in youth was associated with economic hardship level and park area per capita. Thus, the built environment and disadvantaged areas may contribute in significant ways to childhood obesity.

The Poverty of Time

The loss of manufacturing jobs, the growth of a service economy and the increasing number of women in the labor force have been associated with a dramatic shift in family eating habits, from the decline of the family dinner to the emerging importance of snacks and fast foods. The allocation of time resources by individuals and households depends on socioeconomic status.

The concept of “time poverty” addresses the difficult choices faced by lower income households. When it comes to diet selection, the common tradeoff is between money and time. One illustration of the dilemma is provided by the Thrifty Food Plan (TFP), a recommended diet meeting federal nutrition recommendations at the estimated cost of $27 per person per week. While this price is attractive, it has been estimated that TFP menus would require the commitment of 16 hours of food preparation per week. By contrast, a typical working American woman spends only 6 hours per week, whereas a non-working woman spends 11 hours per week preparing meals . Thus, TFP may provide adequate calories at low cost, but requires an unrealistic investment in time. ( See, Caprio S, Daniels SR, Drewnowski A, Kaufman FR, Palinkas LA, Rosenbloom AL, Schwimmer JB Influence of race, ethinicity, and culture on childhood obesity: implications for prevention and treatment: a consensus statement of Shaping America’s Health and the Obesity Society. Diabetes Care 2008 Nov;31(11):2211-21. Influence of race, ethnicity, and culture on child…[Obesity (Silver Spring). 2008] – PubMed Result)

It is useful to consider that weight management is not the only thing people have to do. Time taken for physical activity and nutritional improvement is going to be time taken away from other activities, such as care for self and others, self-improvement, community activities and volunteering, time with children and family members, and recreation (including television viewing and using a computer/Internet)

Intrusive wellness programs have the potential to interfere with the employees’ right to privacy and complicate the doctor-patient relationship. Under the Safeway plan, for example, an employee can request an exception on recommendation of a physician. To whom the employee can request this is not clear. Nor is it clear under what circumstances the exception would be granted. Look at two common scenarios:

1. The employee has a disease like HIV/AIDs or cancer in which weigh loss is common and his or her physician does not want the employee to lose any weight if they can help it. Would the employee have to reveal this condition?

2. The employee has common diseases like type 2 diabetes or depression. The physician has recommended drugs which actually cause weight gain. Does the employee have to disclose this? What if the employer decides that another medication could be used? Does now the doctor, patient and often managed care plan have to discuss medical alternatives with Human Resources? In other words, will the employees health be endangered by the effort to live a healthy lifestyle?

Who is disadvantaged by employer wellness program? Programs such as Safeway’s may have unintended discriminatory effects. The biometrics used in such programs, to the extent they include obesity, elevated triglycerides and blood pressure, are part of what is known as the metabolic syndrome. Approximately 34% of adults meet the National Cholesterol Education Program’s criteria. Older males and females from 40-59 years of age are about 3 times as likely as those 20-39 to meet the criteria for the metabolic syndrome. Males and females over 60 were more than 4 and 6 times respectively to meet the criteria. Overweight and obese males were 6 and 32 times as likely as normal weight males to the meet the criteria and overweight and obese females were 5 and 17 times as likely to meet the criteria. (See, Ervin RB, Prevalence of metabolic syndrome among adults 20 years of age and over, by sex, age, race and ethnicity, and body mass index: United States, 2003-2006. National Health Statistics Reports; No. 13.National Health Statistics metabolic syndrome – PubMed Results )

Therefore, we can expect that such programs deliver little in the way of improvements in individual’s body weight, while having a disproportionate impact on minorities, the elderly and those with serious health conditions. To the extent that these employees see a reduction in their health insurance (possibly to the point of zero if the 20% limitation is totally removed), they will only increase the ranks of the uninsured, thereby frustrating the whole purpose of health care reform.

For further information, see;

Insurance coverage and incentives for weight loss …[Obesity (Silver Spring). 2008] – PubMed Result

Effects of a reimbursement incentive on enrollment…[Obesity (Silver Spring). 2007] – PubMed Result

Worksite Opportunities for Wellness (WOW): Effects…[Prev Med. 2009] – PubMed Result

The Working Healthy Project: a worksite health-pro…[J Occup Environ Med. 1999] – PubMed Result

LEAN Works: About CDC’s LEAN Works | DNPAO | CDC

Public Health Strategies for Preventing and Controlling Overweight and Obesity in School and Worksite Settings </P><P>A Report on Recommendations of the Task Force on Community Preventive Services

Financial incentive-based approaches for weight lo…[JAMA. 2008] – PubMed Result

Health Care Reform and Obesity – The Issues

September 27th, 2009

The current health care reform debate has crucial implications for the prevention and treatment of obesity. This debate will be followed closely in the months, if not years, ahead. Here is my view of some of the critical issues in the current debate. MD

October 16, 2009

Senate Finance wellness loophole undercuts reform goals.  Wellness Incentives Could Create Health-Care Loophole – washingtonpost.com

————————— 

Has America Reached its Tipping Point on Obesity?

downey_youtube 

The two most recent surgeons general, Dr. David Satcher, left, and Richard H. Carmona, center, join Morgan Downey, right, at the STOP Obesity Alliance panel discussion at the Newseum in September. 

The recommendations of the group will provide policymakers guidelines in dealing with obesity in forthcoming reform bills. STOP Obesity Alliance 

Richard H. Carmona, M.D., M.P.H., STOP Obesity Alliance Health & Wellness Chairperson, 17th Surgeon General of the United States (2002-2006) Richard H. Carmona, M.D., M.P.H., STOP Obesity Alliance Health & Wellness Chairperson, 17th Surgeon General of the United States (2002-2006) 

David Satcher, M.D., M.P.H., The Satcher Leadership Institute Director, 16th Surgeon General of the United States (1998-2002) David Satcher, M.D., M.P.H., The Satcher Leadership Institute Director, 16th Surgeon General of the United States (1998-2002) 

Jeff Levi, Ph.D., Trust for America’s Health Jeff Levi, Ph.D., Trust for America’s Health 

Christine Ferguson, J.D., STOP Obesity Alliance. Christine Ferguson, J.D., STOP Obesity Alliance Director. 

 

Helen Darling, National Business Group on Health Helen Darling, National Business Group on Health 

 

 

August 11, 2009

President Obama calls for health insurance reform to cover obesity treatments, stating, “All I’m saying is let’s take the example of something like diabetes, one of — a disease that’s skyrocketing, partly because of obesity, partly because it’s not treated as effectively as it could be. Right now if we paid a family — if a family care physician works with his or her patient to help them lose weight, modify diet, monitors whether they’re taking their medications in a timely fashion, they might get reimbursed a pittance. But if that same diabetic ends up getting their foot amputated, that’s $30,000, $40,000, $50,000 — immediately the surgeon is reimbursed. Well, why not make sure that we’re also reimbursing the care that prevents the amputation, right? That will save us money. Text – Obama’s Health Care Town Hall in Portsmouth – NYTimes.com

July 27-29

Centers for Disease Control and Prevention hold Weight of the Nation Conference in Washington, D.C. Speakers include former President Bill Clinton and HHS Secretary, Katherine Sebelius. For full conference information go to CDC Features – Weight of the Nation

July 12, 2009

From Morgan Downey: The ways in which health care reform can address obesity

  1. Prevalence of Obesity in Uninsured Population

There appears to be a high prevalence of overweight and obesity in the uninsured population. A study published in 2000, indicated that, “Smokers, obese individuals, and binge drinkers, were more often uninsured than adults without these risk factors. In contrast, people with self-reported hypertension, diabetes mellitus, and elevated cholesterol were less likely to be uninsured than adults without these conditions.” Ayanian, JZ, Weissman, JS, Schneider EC, Unmet Health Needs of Uninsured Adults in the United States, JAMA, 2000;284:2061-2069. Free full text at Unmet Health Needs of Uninsured Adults in the United States — Ayanian et al. 284 (16): 2061 — JAMA

Likewise, it is estimated that nearly half of all uninsured, non-elderly adults report having a chronic condition. Common reported chronic conditions are diabetes, hypertension, arthritis-related conditions, high cholesterol, asthma and heart disease, all of which are either caused by or highly associated with, overweight and obesity. “Uninsured American with Chronic Health Conditions: Key Findings from the National Health Interview Survey, Uninsured Americans With Chronic Health Conditions: Key Findings from the National Health Interview Survey – RWJF

2. Limiting Use of Pre-Existing Conditions

When individuals, outside of group plans, with obesity try to purchase health insurance policies on an individual basis, they find they are unwelcome. Many private health insurance programs exclude individuals with certain Body Mass Index from accessing individual policies. According to F as in Fat report by the Trust for America, many companies will charge additional premiums for persons with a BMI between 30 and 39. Over a BMI of 39, a person may find no company willing to provide individual coverage. Other plans may classify persons as “unhealthy” or “uninsurable” due to obesity. Companies are free to make their own definitions of these terms. Few states restrict these practices. 14-14 (See F as in Fat: How Obesity Policies Are Failing in America 2008 – RWJF)

Even if the person with obesity can overcome the weight hurdle, their coverage may be limited by the use of the common ‘pre-existing condition’ requirements which restrict a person for a period of time from accessing their plan’s benefits. As indicated above, many chronic diseases are associated with obesity and these can form additional hurdles to obtaining needed care.

Some health insurance plans have started to take very small steps to deal with obesity. For the most part, these efforts include bariatric surgery for additional premiums or offering employer’s a worksite wellness program, also for an additional payment.

Finally, few states have any kind of mandated benefits related to obesity treatment or prevention. In such cases, the insurance industry typically fights such proposals extremely vigorously. (See statement of Bob Clegg former Republican majority Senate leader, New Hampshire at The Challenge of Obesity for Policy Makers: Recommendations for the Next Administration: Republican Convention Forum – health08.org)

  1. Coverage of Obesity Interventions

Once insured the question arises, “Will offered health plans address obesity prevention and treatment?” If the uninsured health plan does not address the, or one of the, root cause of an individual’s health concerns, will any progress be made in using this entire health reform effort to improve individual and public health? The current situation of health insurance, in its avoidance of obesity prevention and treatment, perpetuates a focus on the conditions caused by obesity. Millions spent on heart disease or type 2 diabetes (not to mention the other ill effects, see above) will only continue. Only by addressing the root problem will Americans and America’s health see improvement.

The question has been raised of using the Medicare and Medicaid coverage criteria as the model for the legislation’s covered services. In terms of obesity, these programs cover obesity treatment and prevention inconsistently and inadequately. Regarding Medicare,

  1. In 2004, Medicare eliminated language in its coverage manual to the effect that obesity was not a disease. This opened the door to treat obesity in its own right as a disease.
  2. In February 2006, CMS significantly expanded its national coverage policies to cover more bariatric surgery procedures when performed in designated centers of excellence.
  3. Medicare Part D does not cover drugs for the treatment of obesity.
  4. Medicare does not cover physician or dietetic counseling for weight loss.

Regarding Medicaid,

  1. Most Medicaid plans have no to limited coverage of drugs for the treatment of obesity. The Medicaid statute actually bans states from including such pharmaceutical products but allows a waiver on request of the state. Few states have sought or received such a waiver.
  2. Bariatric surgery, while nominally covered in many states, is subject to such low reimbursement rates that few surgeons want to provide it. Other limitations on is provision further limit its ability to help individuals who meet the NIH recommendations from receiving the surgery.

The Internal Revenue Service, through a change in a revenue ruling in 2000, allows individuals to deduct the costs of weight loss programs upon recommendation of a physician. Of course, taxpayers must meet the threshold of 7.5% of adjusted gross income to qualify for the medical deduction at all. Therefore, Congress should use the expert, evidence-based recommendations of the NIH to decide covered services. (See, http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf)

Similar recommendations adopted by the American Academy of Pediatrics and 15 national medical societies should be adopted by children and adolescents as indicated. (See, Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report — Barlow and and the Expert Committee 120 (4): S164 — Pediatrics)

The Baucus Plan (Call to Action Health Reform 2009, November 12, 2008, Senate Finance Committee) would leave coverage decisions to a new independent health coverage council. This is probably insufficient and Congress should make this decision on coverage of obesity interventions, both prevention and treatment, itself. This would be consistent with the Baucus Plan’s goal, “Prevention must become a cornerstone of the health care system rather than an afterthought. This shift requires a fundamental change in the way individuals perceive and access the system and community-based wellness approaches at the Federal, state, and local levels. With a national culture of wellness, chronic disease and obesity will be better managed and, more importantly, reduced.” (See, http://finance.senate.gov/healthreform2009/finalwhitepaper.pdf (at p. 28)

5. Eliminating the Itemized Deduction

As mentioned earlier, in 2000, the Internal Revenue Service issued a revenue ruling allowing the expenses for weight control which were recommended by a physician to be deductible as a medical expense. While the scope of this ruling is constrained by the limitation that such expenses must exceed 7.5% of adjusted gross income, it is nevertheless the only federal financial support for treatments for obesity outside of the Medicare coverage of bariatric surgery (which is limited to Medicare elderly and non-elderly disabled populations). As such, it should not be modified or repealed unless Congress mandates the benefit package described above.

6. Taxing Sugar-sweetened beverages

The role of sugar sweetened beverages in the increase of obesity, particularly childhood obesity, has been well documented. The evidence from epidemiological and experimental studies indicates that a greater consumption of sugar sweetened beverages is associated with weight gain and obesity.( See, Malik VS, Schulze MB, Hu FB, Intake of sugar-sweetened beverages and weight gain: a systematic review. Am J Clin Nutr 2006;84:274-88. Intake of sugar-sweetened beverages and weight gai…[Am J Clin Nutr. 2006] – PubMed Result) Replacing sugar sweetened beverages with water could result in an average reduction of 235 calories per day. ( See, Wang YC, Ludwig DS, Sonneville K, Gortmaker SL, Impact of changes in sweetened caloric beverage consumption on energy intake among children and adolescents. Arch Pediatr Adolesc Med 2009 Apr; 163(4):336-43.Impact of change in sweetened caloric beverage con…[Arch Pediatr Adolesc Med. 2009] – PubMed Result)

The Senate Finance Committee options, however, do not indicate the level of taxation under consideration. Only a significant tax level is likely to affect consumption and its effect on obesity is predicated on the sugar sweetened beverage not being replaced by foods or beverages of similar caloric value. A significant tax, however, is likely to presage decline in consumption over time with an accompanying decline in tax revenue over that time. Therefore, its contribution to financing tax reform would be offset by its value in reducing obesity. As no state or jurisdiction has undertaken this policy option, there is no way of knowing with some certainty whether obesity levels would fall. This may not be a reason not to impose such a tax.

8. Tax on ‘Cadillac Plans’

Also, proposals have been made to treat as income to employee the costs of “Cadillac” health insurance plans, i.e. those that have extensive benefit packages, very low co-payments or deductibles or both. In regard to obesity, probably most of the health insurance plans which now cover surgery, drugs and behavioral modification for persons with obesity would be regarded as such a plan. To tax the employee for these benefits may undo the goals of obesity prevention and reduction. The time has come for employers and payors to provide comprehensive coverage of obesity treatments. Enactment of a tax on the extra costs of such plans is likely to have a negative effect. (See, Swallowing the Cost of Obesity Treatment | workforce.com)

April 21, 2009

Somerville MA tagged as model for health care reform Mass. town takes steps to trim fat (really), health care costs – USATODAY.com

March 5, 2009

Obama addresses obesity at close of national health care forum The White House – Press Office – Closing Remarks by the President at White House Forum on Health Reform, followed by Q&A, 3/5/09

Feb 4, 2009

President Obama Signs SCHIP Bill, Includes Childhood Obesity Demonstration Project.

The new SCHIP legislation contains a requirement for the Secretary of HHS in consultation with the Centers for Medicare and Medicaid Services to conduct a “systematic model for reducing childhood obesity.” The model is intended to identify behavioral risk factors for obesity through self-assessment, identify, through self-assessment, needed clinical preventive and screening benefits among children identified as target individuals on the basis or such risk factors and provide ongoing support to such individuals to reduce risk factors and promote use of preventive and screening benefits and “be designed to improve health outcomes, satisfaction, quality of life, and appropriate use of items and services available under Title 19 (Medicaid) or Title 21.

November 30, 2008

CEO’s Talk Up Obesity CEOs’ Healthcare-Reform Priorities: Obesity and Tort Reform, But Not Universal Coverage | BNET Healthcare Blog | BNET

August, 2008

For the first time in history, the two major political parties in the United States recognized the importance of obesity in their respective party platforms

Democratic Party Platform addresses obesity

The Democratic Platform, adopted in Denver, Colorado on 25 August 2008, refers to obesity three times:

“Our nation faces epidemics of obesity and chronic diseases as well as new threats like pandemic flu and bioterrorism. Yet despite all of this, less than four cents of every health care dollar is spent on prevention and public health.” (p 8)

An Emphasis on Prevention and Wellness. Chronic diseases account for 70 percent of the nation’s overall health care spending. We need to promote healthy lifestyles and disease prevention and management especially with health promotion programs at work and physical education in schools. All Americans should be empowered to promote wellness and have access to preventive services to impede the development of costly chronic conditions, such as obesity, diabetes, heart disease, and hypertension.” (p 9)

Public Health and Research. Health and wellness is a shared responsibility among individuals and families, school systems, employers, the medical and public health workforce and government at all levels. We will ensure that Americans can benefit from healthy environments that allow them to pursue healthy choices. Additionally, as childhood obesity rates have more than doubled in the last 30 years, we will work to ensure healthy environments in our schools.” (p 10)

A forum on obesity was held by the Obesity Society. The forum at the Democratic National Convention, held on 25 August 2008 at the Denver Art Museum, featured Gary Foster, president, James Hill and Robert Eckel of the University of Colorado, past presidents, and Caroline Apovian with Melody Barnes, Director of Policy for the Obama for President Campaign, and Karen Kornbluh, principal author of the 2008 Democratic Party Platform. Also presenting were Congressman and chairman of the Congressional Black Caucus John Conyers (D-MI-14), Jim Rex, Superintendent of Education in South Carolina and R.T. Rybak, Mayor of Minneapolis, Minnesota. Sally Squires, former columnist for the Washington Post and founder of the Lean Plate Club, moderated the event. Discussions ranged far and wide about expanding treatment and improving prevention of obesity, especially the role of schools in childhood obesity.

The Republican Party Platform, adopted a week later in St Paul, Minnesota, provides:

“Prevent Disease and End the ‘Sick Care’ System. Chronic diseases—in many cases, preventable conditions—are driving health care costs, consuming three of every four health care dollars. We can reduce demand for medical care by fostering personal responsibility within a culture of wellness, while increasing access to preventive services, including improved nutrition and breakthrough medications that keep people healthy and out of the hospital. To reduce the incidence of diabetes, cancer, heart disease and stroke we call for a national grassroots campaign against obesity, especially among children.”

On 2 September 2008, The James L. Hill Research Library in St Paul, Minnesota, was the scene of the Republican forum. Speakers included Caroline Apovian, Eric Finkelstein, and Michael Jensen, also a past president of the Society. Allen Levine and Charles Billington (another past president) presented welcoming statements from the University of Minnesota. Lesley Stahl, correspondent on CBS News’ 60 Minutes, moderated a panel consisting of former Secretary of Health and Human Services, Tommy Thompson, representing the campaign of Senator John McCain, former Presidential candidate and Arkansas Governor, Mike Huckabee and State Senator Bob Clegg of New Hampshire. Huckabee enthralled the audience with accounts of trying to get attention to health care issues and obesity in the presidential debates and within his own party. Bob Clegg told his personal story of his fight with obesity and subsequent bariatric surgery. Clegg was the Republican majority leader in the New Hampshire State Senate, and push through the legislature, a bill mandating insurance companies cover bariatric surgery. His personal story combined with the legislative maneuvering was compelling.

Video and transcript of Republican National Convention Forum is available at: http://www.kaisernetwork.org/
health_cast/health2008hc.cfm?hc=2970

Video and transcript of Democratic National Convention Forum is available at: http://www.kaisernetwork.org/
health_cast/health2008hc.cfm?hc=2962

The video and transcript of the 19 September 2007 forum on what the next administration should do can be found at: http://www.kaisernetwork.org/
health_cast/hcast_index.cfm?display=detail&hc=2353

Obesity A-Z

September 26th, 2009

There are numerous issues involved in understanding, preventing and treating obesity. Specific diseases are treated in the Health Effects section. Below are a number of other issues. The citations are not meant to be exhaustive but merely to help the reader begin the search for various sources of information. MD

Adherence

Adherence can also be called willpower or compliance. It refers to individual behavior continuing a program of recommended advice, from following a diet to taking medications. Adherence or compliance is a major issue in health care.

http://obssr.od.nih.gov/pdf/Workshop_final_report.pdf

In spite of many efforts to improve Americans life style, the percentage of Americans following all five recommendations has dropped to an all time low – just 8% Adherence to healthy lifestyle habits in US adults…[Am J Med. 2009] – PubMed Result

For more information, see NIH Office of Behavioral and Social Sciences Research (OBSSR) – Adherence

Adiponectin

Higher adiponectin levels associated with lower risk of type 2 diabetes Adiponectin levels and risk of type 2 diabetes: a …[JAMA. 2009] – PubMed Result

Adipose Tissue

Obesity is about excess adipose tissue. However, adipose tissue is essential for survival and reproduction of the species. In excess amounts, it can, of course cause poor health and early mortality. Researchers have made great strides in understanding this tissue.

The perfect storm: obesity, adipocyte dysfunction,…[Clin Chem. 2008] – PubMed Result

Impact of increased adipose tissue mass on inflamm…[Curr Diab Rep. 2009] – PubMed Result

The role of adipose tissue dysfunction in the path…[Physiol Behav. 2008] – PubMed Result

Fat storage and the biology of energy expenditure. [Transl Res. 2009] – PubMed Result

Adiposity Rebound

Adiposity or fatness increases in the first of year of life and then decreases. About age 6, fatness increases again. This is called adiposity rebound and it is considered to be a critical time when the conditions for adult obesity can become established.

Early adiposity rebound: review of papers linking …[Curr Opin Clin Nutr Metab Care. 2005] – PubMed Result

Adolescence

Food companies targeting adolescence in the digital age Interactive food and beverage marketing: targeting…[J Adolesc Health. 2009] – PubMed Result

Maternal gestational weight gain and offspring wei…[Obstet Gynecol. 2008] – PubMed Result

Adolescent pregnancy and subsequent obesity in Afr…[J Adolesc Health. 1994] – PubMed Result

Changes in physiology with increasing fat mass. [Semin Pediatr Surg. 2009] – PubMed Result

Drugs shown to have efficacy, safety for adolescents Efficacy of weight loss drugs on obesity and cardi…[Obes Rev. 2009] – PubMed Result

No difference between obese and non-obese adolescent food consumption Comparison of high-calorie, low-nutrient-dense foo…[Obes Res. 1999] – PubMed Result

Problem eating behaviors Problem eating behaviors related to social factors…[Int J Behav Nutr Phys Act. 2007] – PubMed Result

Changes in adolescent beverage consumption Five-year longitudinal and secular shifts in adole…[J Am Diet Assoc. 2009] – PubMed Result

And in physical activity Longitudinal and secular trends in physical activi…[Pediatrics. 2006] – PubMed Result

International Journal of Obesity – Clinical research in adolescents: challenges and opportunities using obesity as a model

Comorbidities of overweight/obesity experienced in…[Arch Dis Child. 2009] – PubMed Result

Longitudinal and secular trends in weight-related …[Obesity (Silver Spring). 2008] – PubMed Result

Overweight, obesity, and health-related quality of…[Pediatrics. 2005] – PubMed Result

Depression in adolescents A prospective study of the role of depression in t…[Pediatrics. 2002] – PubMed Result

Agricultural subsidies

No effect on obesity, from USDA http://www.agecon.ucdavis.edu/extension/update/articles/v11n2_1.pdf

EconPapers: Farm subsidies and obesity in the United States: National evidence and international comparisons

Are rising obesity rates linked to U.S. farm aid? | McClatchy

Farm Subsidies Over Time

ScienceDirect – Food Policy : Farm subsidies and obesity in the United States: National evidence and international comparisons

Alcohol Calorie Calculator

http://www.collegedrinkingprevention.gov/CollegeStudents/calculator/alcoholcalc.aspx

Basal Metabolic Rate

The basal metabolic rate (closely related to the resting metabolic rate) is the amount of calories our bodies need to just maintain their normal functions, like metabolism, breathing, blood flow, etc. It is the baseline for determining one’s caloric input.

Basal Metabolism Rate Calculator (note: BMR calculators can have a high degree of variation : BMR Calculator

Breakfast

Is consumption of breakfast associated with body m…[J Am Diet Assoc. 2005] – PubMed Result

Breast-feeding

Mothers more likely to cease breastfeeding The association of maternal overweight and obesity…[J Pediatr. 2006] – PubMed Result

Overweight obese mothers less likely to breastfeed. A systematic review of maternal obesity and breast…[BMC Pregnancy Childbirth. 2007] – PubMed Result

Breastfeeding in infancy and adult cardiovascular …[Am J Med. 2009] – PubMed Result

Australian study shows mothers with obesity more likely to cease breastfeeding Maternal obesity and initiation and duration of br…[Matern Child Nutr. 2008] – PubMed Result

Exclusive breastfeeding of Swedish children and it…[BMC Pediatr. 2008] – PubMed Result

Calculators

Calories Burned UMMS: Calories Burned Calculator

Canada

See Canadian Obesity Network – Obesity Canada

Quality of life of patients with obesity The health status of obese individuals in Canada. [Int J Obes Relat Metab Disord. 2001] – PubMed Result

Prevalence of obesity in Canada. [Obes Rev. 2005] – PubMed Result

BMI and Mortality: Results From a National Longitu…[Obesity (Silver Spring). 2009] – PubMed Result

Child Abuse

Childhood maltreatment in extremely obese male and…[Obes Res. 2005] – PubMed Result

Relation of childhood sexual abuse and other forms…[Obes Surg. 2006] – PubMed Result

Childhood sexual abuse and obesity. [Obes Rev. 2004] – PubMed Result

Child abuse is associated with both obesity and depression in middle age women

Associations of child sexual and physical abuse wi…[Child Abuse Negl. 2008] – PubMed Result

Obesity risk for female victims of childhood sexua…[Pediatrics. 2007] – PubMed Result

Obesity and type 2 diabetes risk in midadult life:…[Pediatrics. 2008] – PubMed Result

Common Sense

‘Common sense’ when used to describe some obesity intervention usually is short for “there’s no data to support this.” Usually within 18 to 24 months there is study showing the ‘common sense’ recommendation didn’t work.

Cuba

Cuba presents an interesting case study. With the fall of the Soviet Union, Cuba, faced with reduction of subsidies from their former patron, went into an economic crisis, known as the “Special Period.” As a result, calories consumed per day dropped, physical activity increased and there was a modest 1.5 unit shift in BMI with reductions in obesity prevalence and increases in overweight and normal weight. Deaths attributed to diabetes, coronary heart disease, stroke and all causes declined as well, suggesting population wide measures might reduce disease and increase mortality. Obesity reduction and its possible consequences: w…[CMAJ. 2008] – PubMed Result and Impact of energy intake, physical activity, and po…[Am J Epidemiol. 2007] – PubMed Result (While the Cuban experience is an extremely interesting situation, the question must be asked whether a democratic government not in extreme economic peril could impose such a draconian situation on its people. MD)

Disparities

While rates of obesity are increasing in all demographic categories, large difference between groups are very evident, leading researchers to ask why different groups in the same environment should have such divergent outcomes.

Obesity, Gynecological Factors, and Abnormal Mammo…[J Womens Health (Larchmt). 2009] – PubMed Result

State of disparities in cardiovascular health in t…[Circulation. 2005] – PubMed Result

Disparities in preventive care by body mass index …[Women Health. 2008] – PubMed Result

The obesity epidemic in the United States–gender,…[Epidemiol Rev. 2007] – PubMed Result

Racial divergence in adiposity during adolescence:…[Pediatrics. 2001] – PubMed Result

Gender-ethnic disparity in BMI and waist circumfer…[Obesity (Silver Spring). 2009] – PubMed Result

Women Obesity in black women. [Epidemiol Rev. 1987] – PubMed Result

Eating Behavior

The psychology of food craving. [Proc Nutr Soc. 2007] – PubMed Result

RAND | RAND Health | Eating as an Automatic Behavior

Food cravings and energy regulation: the character…[Int J Obes (Lond). 2007] – PubMed Result

Eating Disorders

[Night eating syndrome and nocturnal eating–what …[Psychother Psychosom Med Psychol. 2009] – PubMed Result

Teasing history, onset of obesity, current eating …[Obes Res. 2000] – PubMed Result

Childhood psychological, physical, and sexual malt…[Obes Res. 2001] – PubMed Result

Eating disorders and obesity: two sides of the sam…[Epidemiol Psichiatr Soc. 2009 Apr-Jun] – PubMed Result

http://www.womenshealth.gov/BodyImage/bodyworks/CompanionPiece.pdf

Does talking about weight lead to eating disorders? A Parent’s Innocent Word Can Trigger a Dangerous Eating Disorder – washingtonpost.com

Role of parents: Risk Factors for Full- and Partial-Syndrome Early …[J Am Acad Child Adolesc Psychiatry. 2009] – PubMed Result

Elderly

Obesity: What is an elderly population growing int…[Maturitas. 2009] – PubMed Result

Elderly risk for obese men Overweight and obesity and the burden of disease a…[Int J Obes Relat Metab Disord. 2004] – PubMed Result

Applicability of Federal Guidelines An evidence-based assessment of federal guidelines…[Arch Intern Med. 2001] – PubMed Result

Fat or Fit Debate

Relationship between low cardiorespiratory fitness…[JAMA. 1999] – PubMed Result

Fitness and abdominal obesity are independently as…[J Intern Med. 2009] – PubMed Result

Food

The obesity-by-choice debate. Effect of nutrient composition Obesity by choice revisited: effects of food avail…[Physiol Behav. 2007] – PubMed Result

Biology trumps knowledge in model of food choices Is Dietary Knowledge Enough? Hunger, Stress, and Other Roadblocks to Healthy Eating

USDA Food Plans: Cost of Food Cost of Food at Home

Eating and Health Module (ATUS)

Food and Beverage Marketing

See Institute of Medicine Report, Food Marketing and the Diets of Children and Youth – Institute of Medicine

CDC Congressional Testimony CDC Washington Testimony September 23, 2008

Use of branded web sites Food and beverage brands that market to children a…[J Nutr Educ Behav. 2009 Sep-Oct] – PubMed Result

Use of cartoon and other characters Marketing foods to children and adolescents: licen…[Public Health Nutr. 2009] – PubMed Result

The ‘Sydney Principles’ for reducing the commercia…[Public Health Nutr. 2008] – PubMed Result

Glycemic Index

Low glycaemic index or low glycaemic load diets fo…[Cochrane Database Syst Rev. 2007] – PubMed Result

Hunger

Hunger as powerful, primordial emotion The role of primordial emotions in the evolutionar…[Conscious Cogn. 2009] – PubMed Result

Ireland

Prevalence of overweight and obesity on the island…[BMC Public Health. 2007] – PubMed Result

Intensive Care

Effect of obesity on intensive care morbidity and …[Crit Care Med. 2008] – PubMed Result

Menu Labeling

Menu Labeling in Food Chains http://www.yaleruddcenter.org/resources/upload/docs/what/reports/RuddMenuLabelingReport2008.pdf

Microorganisms

Fat Factors – New York Times

Obesity – Extending the Hygiene Hypothesis. [Nestle Nutr Workshop Ser Pediatr Program. 2009] – PubMed Result

Interplay between obesity and associated metabolic…[Curr Opin Pharmacol. 2009] – PubMed Result

Gut microbiota and its possible relationship with …[Mayo Clin Proc. 2008] – PubMed Result

Military

Military family physician attitudes toward treatin…[Mil Med. 2008] – PubMed Result

Attitudes and practices of military family physici…[Mil Med. 2001] – PubMed Result

Mortality

For many years, the issue of whether obesity causes an increase in premature deaths has been hotly debated. The public frequently receives conflicting information on the topic. Is it ok to be overweight? Are only persons with severe obesity at risk? In the final analysis, I think the American Heart Association’s Scientific Consensus gets it right…at some point (the curve of body weight) the heavier have higher rates of premature deaths. At what exact point on the BMI scale that takes place is open to discussion, but the curve always goes up. MD)

See Mortality, health outcomes, and body mass index in…[Circulation. 2009] – PubMed Result

An August 2009 study shows obesity is responsible for about 95 million Years-of-Life-Lost. White femals account for more than 2/3 of that amount. Without changes in the obesity prevalence, the life expectancy of US adults may decrease. Individual and Aggregate Years-of-life-lost Associ…[Obesity (Silver Spring). 2009] – PubMed Result

New: Study estimates overweight/obesity and physical inactivity each responsible for 1 in 10 deaths in the US.The preventable causes of death in the United Stat…[PLoS Med. 2009] – PubMed Result

Will the rise in obesity affect future mortality rates? Trends in Health Behaviors and Health Outcomes

The preventable causes of death in the United Stat…[PLoS Med. 2009] – PubMed Result

Optimal Body Weight for the Prevention of Coronary…[Obesity (Silver Spring). 2009] – PubMed Result

Will the rise in obesity affect future mortality rates? Trends in Health Behaviors and Health Outcomes

Does intentional weight loss increase longevity? Long-term weight loss effects on all cause mortali…[Obes Rev. 2007] – PubMed Result

Obesity and Mortality after Stroke The Impact of Body Mass Index on Mortality After S…[Stroke. 2009] – PubMed Result

Preventable causes of death The preventable causes of death in the United Stat…[PLoS Med. 2009] – PubMed Result

Effect of physical inactivity Effects of physical inactivity and obesity on morb…[Med Sci Sports Exerc. 1999] – PubMed Result

Obesity, Mortality and Nursing Home Residents Obesity and mortality in elderly nursing home resi…[J Gerontol A Biol Sci Med Sci. 2005] – PubMed Result

Morbid obesity is an independent determinant of de…[Crit Care Med. 2006] – PubMed Result

The body mass index paradox and an obesity, inflam…[Semin Dial. 2004 May-Jun] – PubMed Result

Overweight, obesity, and mortality from cancer in …[N Engl J Med. 2003] – PubMed Result

Nursing Homes

Elderly in nursing homes Obesity in nursing homes: an escalating problem. [J Am Geriatr Soc. 2005] – PubMed Result

Oral Bacteria

Is obesity caused by an oral bacteria? Is obesity an oral bacterial disease? [J Dent Res. 2009] – PubMed Result

Pets

The young and old, rich and poor, black and white are becoming more obese. Is it any wonder that our pets would also see increases in their weight? As a matter of fact, veterinarians are very concerned about obesity in pets and have even formed a society to address the problem. See Pet Obesity Facts and Risks

Overweight in dogs, but not in cats, is related to…[Public Health Nutr. 2009] – PubMed Result

Portion Size/Control

The contribution of expanding portion sizes to the…[Am J Public Health. 2002] – PubMed Result

The influence of food portion size and energy dens…[Am J Clin Nutr. 2005] – PubMed Result

Energy density and portion size: their independent…[Physiol Behav. 2004] – PubMed Result

Public Health

Prevalence of selected risk behaviors and chronic …[MMWR Surveill Summ. 2008] – PubMed Result

Reimbursement

Should medicare reimburse providers for weight los…[Am Psychol. 2007] – PubMed Result

http://www.obesityaction.org/advocacytools/insurance/OAC%20Insurance%20Piece.pdf

Social Networks

In the past couple of years, researchers have been exploring new theories for the rapid spread of obesity. One of these areas is social networks of individuals, i.e. their close friends and relatives.

One of the earlier studies can be found here The spread of obesity in a large social network ov…[N Engl J Med. 2007] – PubMed Result but also see Adolescent obesity and social networks. [Prev Chronic Dis. 2009] – PubMed Result

Weight loss may positively impact spouses Weight loss treatment influences untreated spouses…[Int J Obes (Lond). 2008] – PubMed Result

Stress

Shaping the stress response: interplay of palatabl…[Mol Cell Endocrinol. 2009] – PubMed Result

Chronic stress and comfort foods: self-medication …[Brain Behav Immun. 2005] – PubMed Result

Role of stress and weight gain Stress and obesity: the role of the hypothalamic-p…[Curr Opin Endocrinol Diabetes Obes. 2009] – PubMed Result

Sugar sweetened Beverages

Sugar-sweetened soft drinks and obesity: a systema…[Nutr Res Rev. 2008] – PubMed Result

Soft drinks and weight gain: how strong is the lin…[Medscape J Med. 2008] – PubMed Result

Intake of sugar-sweetened beverages and weight gai…[Am J Clin Nutr. 2006] – PubMed Result

Soft drinks and weight gain: how strong is the lin…[Medscape J Med. 2008] – PubMed Result

Sugary soda consumption and albuminuria: results f…[PLoS One. 2008] – PubMed Result

Soft drinks and ‘desire to drink’ in preschoolers. [Int J Behav Nutr Phys Act. 2008] – PubMed Result

Taxing Soft Drinkshttp://www.yaleruddcenter.org/resources/upload/docs/what/reports/RuddReportSoftDrinkTaxFeb2009.pdf

Taste

What is role of taste and obesity Taste and weight: is there a link? [Am J Clin Nutr. 2009] – PubMed Result

Technology

Smartphone apps for weight loss Smartphone Training Apps Help You Sweat the Details – NYTimes.com

Computerized BMI prompt increases counseling Effect of a computerized body mass index prompt on…[Fam Med. 2009 Jul-Aug] – PubMed Result

Television Viewing

According to this study, food advertising on TV is a major contributor to childhood obesity By how much would limiting TV food advertising red…[Eur J Public Health. 2009] – PubMed Result

http://www.nber.org/digest/aug06/aug06.pdf

Association between television viewing and poor di…[Int J Pediatr Obes. 2008] – PubMed Result

The association of television and video viewing wi…[Obesity (Silver Spring). 2006] – PubMed Result

Television viewing and television in bedroom assoc…[Pediatrics. 2002] – PubMed Result

Association of maternal obesity and depressive sym…[Arch Pediatr Adolesc Med. 2003] – PubMed Result

Time

USDA: Why working parents outsource children’s meals 2008 Farm Act Makes It Easier for Food Assistance Households To Save – Amber Waves March 2009

Eating and Health, USDA time use study data Eating and Health Module (ATUS) – ERS/USDA Data

Who has time to cook? Who Has Time To Cook? How Family Resources Influence Food Preparation

Americans of different weights spend same amount of time eating How Much Time Do Americans Spend Eating? – June 2008

United Kingdom

Tackling Obesities: Future Choices Project

Vending Machines

Vending machine offerings unhealthy The food and beverage vending environment in healt…[Pediatrics. 2009] – PubMed Result

Virus

Adenovirus Picture: adenovirus Ad-36 (implicated in obesity epidemic) by Russell Kightley MediaOb