How 4 states are fighting obesity
■ Physicians and state public health officials are targeting younger populations to encourage healthy weights and physical activity.
In states like Mississippi, old food habits die hard.
Residents joke that “if anything happens, you bring food. And it's usually a ham,” said Mississippi State Health Officer Mary Currier, MD, MPH. “Trying to change that food culture to bringing something other than a ham is very difficult.”
As the state with the highest per-capita rate of obesity in the U.S. in 2011, with more than a third of its residents obese, Mississippi is under tremendous pressure to change its culture on food and exercise to ensure the health and well-being of future generations. A September report by Trust for America's Health and the Robert Wood Johnson Foundation projected that two out of three Mississippi residents will be obese in 2030 if the current trajectory persists.
The state is not alone. The sobering projections in the study, “F as in Fat: How Obesity Threatens America's Future 2012,” underscored the nation's struggle with rising obesity rates. Researchers estimated that all 50 states in 2030 will have obesity rates exceeding 44%, leading to millions of additional cases of type 2 diabetes, stroke and coronary heart disease, as well as arthritis and hypertension. Billions of dollars will be wasted through lost economic productivity and skyrocketing medical costs.
The grim landscape sketched in the study is what things might look like “if we don't do more now,” said Jeffrey Levi, PhD, executive director of Trust for America's Health. There is no state that “can sit back and say, 'We're OK.' It really is meant as a wake-up call for everyone.” The report showed how states could avoid significant monetary and human costs if they achieved just a 5% reduction in their residents' average body mass index by 2030.
Addressing obesity in patients is an ongoing priority — and frustrating struggle — for physicians across the country. The American Medical Association addressed the crisis at its Annual Meeting in Chicago in June, approving several policies to support healthy lifestyles and nutrition instruction in public schools.
A closer look at four states in different areas of the country, two of which have some of the highest obesity rates, reveals that patient weight management can be an intensely local and complex problem. States are trying to respond by analyzing their cultural environments to come up with unique solutions, employing schools, child care centers, physicians' offices and even social networks to tackle the problem.
South Dakota says eat your vegetables
In 2010, the Centers for Disease Control and Prevention reported that South Dakota residents were consuming fewer vegetables than any other state in the nation.
“Though we are an agricultural state, the types of foods we mainly produce are not fruits and vegetables,” said Kristin Biskeborn. She's the state nutritionist for South Dakota's Dept. of Health and co-author of a 2011 article in a special obesity edition of South Dakota Medicine, the state medical association's journal. The article also said the state lacks regulations on key measures, such as physical activity in schools and child care centers, and the promotion of active transportation such as biking and walking.
All of these factors probably contribute to the state's obesity trend. It ranked 23rd in the nation in 2011, although Biskeborn's article reported that from 1995 to 2009, the rate of increase in adult obesity was the third-fastest in the country.
The state knew that residents needed to eat more fresh produce, but finding out it was the worst in the U.S. on that measure prompted a call to arms, Biskeborn said.
One strategy has been to capitalize on the state's high percentage of Facebook users, creating several pages on the social networking site to remind people about eating more fruits and vegetables. There's also the Harvest of the Month program, which South Dakota adapted from other states to teach children about fruits and vegetables. The state's “Healthy South Dakota” website discusses that program and other state initiatives to encourage healthier eating and physical activity. As mentioned in the “F as in Fat” study, South Dakota also is one of 34 states and the District of Columbia that have imposed a sales tax on soda.
These efforts have made a difference, especially in younger children: Obesity rates recently have gone below the national average for children 5 to 18. But Biskeborn acknowledges that the state has a long way to go.
From a physician's standpoint, getting patients to change behaviors and lifestyles is a challenge, said Robert Allison, MD, president of the South Dakota State Medical Assn.
Biskeborn's article indicated that many South Dakotans weren't receiving much guidance from doctors on weight loss. In Dr. Allison's view, patients need incentives to be responsible for managing their health. Newly diagnosed diabetes patients, for example, often are motivated to lose weight because they want to avoid medication therapy. Dr. Allison said he sets incremental weight-loss goals for these patients through follow-up visits. If a patient loses weight, he reinforces that success, and then says, “I want you to lose five more pounds in the next visit. How can we do that?”
Mississippi enlists churches, schools
Myriad factors have led Mississippi to become the most obese state in the nation, said Richard deShazo, MD. He's a professor of medicine and pediatrics and former chair of the Dept. of Medicine at the University of Mississippi Medical Center.
In addition to the state's large numbers of fast-food eateries that provide an inexpensive source of high-calorie food, the mechanization of farming has led to unemployment and underemployment in farmworkers. “The high calorie, high-fat diets that farm laborers required have continued to be consumed despite a decrease in caloric requirement with mechanization,” he said.
Dr. deShazo has worked with other health care professionals to adapt the federal “Choose My Plate” nutritional guidance into a program designed for residents with a range of literacy levels to learn healthy eating. Southern Remedy Healthy Living is being employed by state public schools, churches and Scout troops, he said. The Mississippi State Medical Assn. has worked to promote this program throughout the state.
The University of Mississippi Medical Center has formed partnerships to teach Southern Remedy's curriculum in churches, doctor's offices and civic clubs throughout the state. “We have now trained more than 500 individuals in the curriculum as screeners for hypertension and diabetes, and they are now at work,” Dr. deShazo said.
The state also has urged communities to sign joint agreements with schools so local residents can use playgrounds, tracks and gyms when school's out, said the state health department's Dr. Currier.
A 2007 law mandates nutritional lunches and vending machine options as well as minimum physical activity levels in schools. Mississippi has recently seen a decrease in obesity rates for students in kindergarten through fifth grade. Dr. Currier stressed that while all of these specific changes in the law should lead to healthier kids, it's difficult to say whether they have led to a drop in obesity rates for this age group.
Steve Demetropoulos, MD, president of the MSMA, said a major part of the obesity strategy for Mississippi begins with children. As an emergency physician, he gets frustrated when he sees people in the ED eating processed foods and adults passing on bad food habits to children. Some kids already weigh 130 pounds when they should be only 60, he said.
By educating children about the importance of healthy eating and exercise, and getting them away from television and video games, “they grow up with this kind of mindset and pass that on to their kids. I think that's how we're going to succeed with this,” Dr. Demetropoulos said.
Michigan struggles under tight budgets
The Centers for Disease Control and Prevention ranked Michigan as the fifth most obese state in 2011. Recognizing that they had data gaps in identifying obesity problems among children, officials recently added a new tool that calculates BMIs to the state immunization registry. Pediatricians and other physicians can elect to record patient height and weight in the registry, said Gwen Imes, program manager for the physical activity, nutrition and obesity prevention program with the Michigan Dept. of Community Health.
The system automatically calculates children's BMIs and provides clinical decision support to physicians using guidance that doctors can print out, Imes said.
The Michigan State Medical Society, a member of the Healthy Kids, Healthy Michigan childhood obesity prevention coalition, has worked with a consultant to determine best practices for dealing with obesity in pediatric offices. The society also supports the state's Health and Wellness 4 x 4 Plan, an effort that focuses on four healthy behaviors: getting regular exercise, eating a healthy diet, avoiding tobacco, and undergoing an annual physical. It also encourages people to become familiar with their BMIs, cholesterol and blood glucose levels, and blood pressure measurements.
Gov. Rick Snyder “has really put the issue of obesity in front of the population. He has called for a wide range of industries and agencies to get involved in the solution to this,” said Dean Sienko, MD. He's the interim chief medical executive for the Michigan Dept. of Community Health and associate dean for prevention and public health at Michigan State University's College of Human Medicine.
Rough economic times, however, have impeded obesity prevention efforts, Dr. Sienko said. Budgets for local health departments have been cut. “That has hurt us in our efforts to try to build healthier communities, things like safe routes to schools, and complete streets and playgrounds and safe places to recreate,” he said.
Imes said some state dollars would help fund the 4 x 4 program. The state also has been pursuing funds from private partners. “We've been working with our communications partners to get this moving as well as working with some coalitions across the state to make this a social movement. A lot of groups said they'd help,” she said.
Colorado does well, but not good enough
At first glance, Colorado appears to be setting the gold standard on weight management. It had the nation's lowest obesity rate in 2011, and the “F as in Fat” study projected that the state in 2030 would have the second-lowest rate (only the District of Columbia would be leaner). Colorado “tends to be a state that attracts a lot of people that are going there to be active and therefore may have healthier adults,” said Levi, of Trust for America's Health.
Fitness definitely is a part of Colorado's ethos, said Shepard Nevel, vice president for policy and evaluation with the nonprofit Colorado Health Foundation. States with high obesity levels also report a correlation with low incomes. “We know that poor families too often have less access to healthy foods and fewer opportunities for walking,” Nevel said. Colorado's median household income is considerably higher than the national average.
But even though Colorado is a relatively prosperous and well-educated state, Nevel said, it faces the same challenges as other states. Although its 2011 obesity rate was 20.7%, “if you look back in time, that's higher than any state's obesity rate in 1995. Mississippi in 1995 had the highest adult obesity rate in the country at 19.4%. By 2010, as the leanest state we had caught up and exceeded that at 19.8%. That's a clear sign of an epidemic nationwide,” he said.
Colorado also faces a tougher challenge with its childhood obesity rate, which has increased at a faster rate than other states, Nevel added. The foundation has focused on increasing physical activity and elevating nutrition standards in schools.
Nevel was confident the state could reverse these trends. As the “F as in Fat” report notes, modest obesity level drops could cut the incidence of serious health conditions for thousands of Coloradans and generate billions of dollars in savings to the state, he said.