By Judith Graham

This story was produced in collaboration with 

Doctors assess patients’ breathing, heart rate and blood pressure routinely at office visits. Soon, they may be adding body mass index to that list too.

Tracking this measure – an indicator of whether someone is obese or overweight – as if it were a vital sign at medical checkups is among a new set of strategies recommended for battling obesity, a concern that some experts predict will affect 42 percent of adults by 2030.

Although professional medical societies have said for years that physicians should monitor patients’ body mass index, most doctors fail to do so.

For example, a 2006 survey of family physicians found that fewer than half checked BMIs for children over the age of 2, even though 71 percent knew this has been recommended.

Just over 40 percent of adult patients in commercial HMOs had documented BMI measurements in 2009 and 2010, according to a survey by the National Committee for Quality Assurance, an organization that evaluates health plans. That figure falls to 12 percent for patients in commercial PPOs, a more common type of plan.

The Institute of Medicine last week called for the medical profession and health insurers to become more rigorous in their approach in a report proposing an anti-obesity campaign that would involve every part of society, from individuals and families to schools, communities, workplaces, the food industry and the media.

Pointing to the more than 90 million children, teens and adults counted as obese, well-established links to medical conditions such as diabetes, hypertension, heart disease, and arthritis, and annual healthcare expenses exceeding $190 billion, the report urged comprehensive and sustained action.

For physicians, monitoring body mass index – a ratio of height to weight – is at the top of the list of priorities because it’s the best way to identify people who have a weight problem. (Adults are counted as obese if they have a BMI of 30 or higher; children if their BMI is at the 95 percentile or higher for kids of the same age and sex.)

“We need to normalize the process of obesity screening and lifestyle counseling so they’re usual and people expect this,” said Dr. Sandra Hassink, a member of the panel that prepared the IOM report and director of the Obesity Initiative at Nemours, a pediatric health system in four states.

Medical Groups Call For Change

Groups such as the American Medical Association and the American Academy of Pediatrics have recommended regular BMI checks for years. Several health care systems also have embraced the practice.

Kaiser includes BMI as a “vital sign” in electronic medical records for nearly 9 million members, and it is planning to do the same for physical activity, another contributor to the obesity epidemic, said Ray Baxter, the plan’s senior vice president for community benefit and health policy. (Kaiser Health News is not affiliated with Kaiser Permanente.)

So why the problem? Many harried physicians are unprepared to advise people about how to change their behaviors, unconvinced they have time to do so, and therefore look skeptically at screening, said Dr. Robert Kushner, clinical director of the Comprehensive Center on Obesity at Northwestern University.

If doctors are overweight themselves, they’re less likely to recognize the issue in their patients, research shows. What’s more, doctors aren’t trained in medical school to handle weight issues.

They also often aren’t convinced obesity treatments work, and many believe there aren’t good community programs to which they can refer patients.

“The question is, how many programs are out there for primary care doctors to refer to in the community, and answer is – not many,” said Dr. Ned Calonge, a Colorado physician who is the immediate past chairman of the U.S. Preventive Services Task Force.

Northwestern is tackling a part of that by weaving instruction in “lifestyle medicine” throughout all four years of a new medical school curriculum being introduced this August.

Another significant problem has been a historic lack of reimbursement from insurers for obesity screening and counseling. That changed last year for seniors, when Medicare said it would cover up to six months of weight loss counseling for obese beneficiaries as part of a package of new preventive services. Nearly 13 million Medicare members are thought to be obese.

Meanwhile, new preventive services guidelines from the government call for all insurance plans to cover obesity screening and counseling without charge to patients.

And insurers are expanding childhood obesity programs following a 2010 recommendation from the U.S. Preventive Services Task Force that endorsed comprehensive weight management programs for youngsters at least 6 years old. Previously, the task force supported BMI screening but not weight loss programs.

Seeking Evidence-Based Programs

For the insurance industry, the challenge now is providing evidence-based programs that can be introduced on a broad scale.

UnitedHealth Group is promoting “Join for Me,” a year-long behavioral modification program piloted with the YMCA of Greater Providence, R.I., in which youngsters 6 to 17 years old, accompanied by a parent, learn about healthy eating and exercise in a group led by a coordinator.

“Doctors are in short supply” and it makes sense to conduct intensive behavioral change programs in the community, not in their offices, said Dr. Deneen Vojta, senior vice president of UnitedHealth’s Center for Health Reform & Modernization.

For overweight and obese adults, the company is looking at offering a version of the Diabetes Prevention Program, a well-studied intensive intervention that has been shown to help people lose weight.

WellPoint has taken a different approach, choosing to work through doctors and with the Alliance for a Healthier Generation, an organization that’s trying to convince health plans to offer more comprehensive coverage for obesity counseling and treatment.

The alliance asks participating plans to offer four visits with a child’s primary care doctor and four visits with a dietitian if the youngster is found to be overweight or obese.

So far several plans, including WellPoint, Aetna, Humana and Highmark, Inc., have signed up, and 2.4 million children are covered.

WellPoint recently launched a limited pilot study of this type of benefit in California and is learning what physicians need and members want before deciding whether to roll it out more broadly, said Harvinder Sareen, clinical program director for the insurance company.

Insurance companies and some self-insured employers are also exploring the use of financial incentives — cash payments or reduced premiums or deductibles – to motivate members to keep their weight in check and to adopt other lifestyle changes.

One program at UnitedHealthcare offers members up to $250 for reaching a BMI of 25 or less, and similar incentives for not smoking and lowering cholesterol and blood pressure.

“Is there coverage [for obesity] is yesterday’s conversation. Today’s conversation is how to design coverage to encourage people to use it and continue using it,” said Karen Ignagni, president of America’s Health Insurance Plans, an industry trade group.

Others disagree that coverage for obesity counseling is adequate.

“The problem is there’s no real incentive for the insurance industry to pay for better prevention and treatment, because the costs are immediate while the benefits are long-term,” said Dr. David Ludwig, director of the new Balance Foundation Obesity Prevention Center at Children’s Hospital, Boston. “Although reducing the prevalence of obesity is one of the most profitable investments the healthcare system could make, it doesn’t make a lot of sense for individual plans when families change policies every three to five years.”

Updated at 2:00 p.m. on May 13 to clarify the description of the NCQA study findings.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

This story was produced in collaboration with 

Since first lady Michelle Obama made childhood obesity her signature project almost two years ago, the issue has had the kind of highly visible national leadership that it previously lacked.

But that isn’t enough, say public health leaders frustrated with the slow progress in stemming America’s obesity epidemic.

Something more ambitious is needed, they argue — something more like the anti-tobacco movement.
The similarities between the two public health challenges are compelling. Tobacco use is the nation’s No. 1 cause of preventable deaths in the U.S., killing 467,000 people in 2005, according to a landmark study by Harvard University researchers.

Being obese or overweight caused an estimated 216,000 deaths from heart disease, diabetes and other conditions, researchers estimated, while another 191,000 deaths resulted from being physically inactive – another key contributor to expanding waistlines.

In terms of health care costs, obesity is now the larger concern, accounting for $147 billion to $190 billion in yearly expenditures, compared to $96 billion for tobacco.

After decades of lawsuits, damning reports about industry practices, and stop-smoking campaigns, smoking rates have plummeted, from a high of 42 percent of adults in 1965 — a year after the first Surgeon General’s report on smoking and health — to just over 19 percent today.

Meanwhile, obesity has been soaring since the 1980s and only last year reached a plateau, which experts say may be only temporary. Currently, 45 million American adults are smokers, while 78 million adults and almost 13 million youngsters are counted as obese.

Some public health advocates see other parallels.

“When I look at what’s going on with obesity, it reminds me of what was going on with tobacco in the 50s, 60s, and 70s, when there was a lot of emphasis on personal responsibility, voluntary self-regulation, and trying to make safe cigarettes,” saidStanton Glantz, director of the Center for Tobacco Control Research and Education at the University of California, San Francisco.

That approach didn’t work, and efforts to reduce smoking didn’t really have much success until advocates shifted their emphasis from changing individual behavior to community-based activism and holding cigarette manufacturers accountable for harmful products, Glantz said.

A similar shift is needed today in the fight against America’s expanding waistlines, many experts believe. Instead of approaching obesity as a personal issue, it needs to be redefined as a community challenge that calls for collective action and wide-ranging policy changes such as more informative food labels, limits on marketing to children, and taxes on unhealthy products, they argue.

But there are many hurdles. The scope of the obesity problem is much larger than tobacco ever was: it touches on the food we eat, the beverages we drink, the amount of television we watch, how much we exercise, the way our cities are designed, and more.

While the variety of policy changes proposed are therefore broader, the political will to enact them has not materialized, in part because “people don’t yet perceive a significant personal threat,” said Dr. William Dietz, director of the division of nutrition, physical activity and obesity at the U.S. Centers for Disease Control and Prevention.

The issue will take center stage in the nation’s capitol this coming week, as the Institute of Medicine releases a new report on strategies to combat the obesity epidemic, the U.S. Centers for Disease Control and Prevention hosts a major conference highlightingefforts to control obesity, and HBO prepares to air a four-part documentary on the obesity crisis.

As public health experts committed to stemming obesity study the history of the anti-tobacco movement and look to it for guidance, it is helpful to consider some key similarities and differences between these issues.

Children are central. The vast majority of people who use tobacco take up the habit as teenagers, and one-third of kids who smoke daily will eventually die prematurely of tobacco-related illnesses, according to the Campaign for Tobacco Free Kids.

The health impact of obesity is similar: seriously overweight children are at greater risk of developing a multitude of health problems that can continue through adulthood, including diabetes, liver disease, heart disease, joint problems and asthma, and are more likely to become obese adults, a wide body of research has demonstrated.

Preventing harm to young people is a central goal of both anti-tobacco and anti-obesity campaigns.

“First, let’s protect our children,” said Dr. David Ludwig, a child obesity expert at Harvard Medical School, noting that the calorie-laden foods and drinks that kids consume in abundance “are not just neutral — they actively undermine our health by overwhelming fundamental biological pathways that regulate appetite and body weight and by manipulating dietary preferences that may be difficult to change over a lifetime.”

Changing social norms is the goal. Dr. Jeffrey Koplan, former head of the CDC and vice president for global health at Emory University in Atlanta, remembers smoking a pipe while writing up patient notes at a prestigious New York hospital in the 1970s. (He gave up the habit more than 30 years ago.)

Today, that would be inconceivable: Smoking rates have been cut by more than half, intolerance of smoking in public places is widespread and anti-smoking policies are in place at hospitals, workplaces, and venues across the country.

Koplan is convinced the same shift in social norms is called for — and achievable — when it comes to childhood obesity.  ”Our (eating and physical activity) tastes, our preferences and our behaviors are learned and can be changed,” he said.

It isn’t going to be easy and it isn’t going to be fast, but “we’re dealing with a population that would like to be thinner and that works in our favor,” he said.

We can’t just say no to food. “Tobacco we can get rid of entirely. We don’t need it. It has no intrinsic value. But we have to eat to live and make terms with food as the enemy,” said Dr. David Katz, director of Yale University’s Prevention Research Center.

That makes curbing childhood obesity a much more complicated issue than tobacco use, Katz and other experts agree. The message to kids and their families can’t be “stop, don’t do this,” which is clear and easy to understand. Instead it has to be “make good choices, do this in moderation, set boundaries,” a message that is considerably more difficult to convey.

Our biology works against us. Throughout most of history, humans lived in an environment where food was scarce and hard to get. As a result, we’re primed, biologically, to eat food when it’s available and “we’re very good at storing calories and defending calories once we’ve got them,” said Dr. Stephen Daniels, chair of the department of pediatrics at the University of Colorado School of Medicine.  ”In some ways, you could say that our biology is our own worst enemy when it comes to being overweight or obese.”

While smoking is highly addictive, the biological responses attached to eating food are even more deeply rooted in human evolution, Katz and other experts said.

A sense of shame and denial is greater. People’s self-image is intimately associated with their body weight in a way that isn’t true of smoking.

“When you talk to kids who are excessively heavy and break through their protective shells, what you find is that they feel terrible about their weight — they feel in many ways that they’ve failed,” Daniels said.

“Obesity is seen as a pejorative term that people don’t connect with. They think ‘I’m just 30 or 40 pounds overweight, but I’m not obese,’” said Dietz of the CDC. That suggests the entire way of talking about the issue may need be reframed before personal and social change becomes possible, he suggested.

The variety of products is larger. Tobacco is a single substance, with a limited set of companies that produce cigarettes and related products.

By contrast, the food and beverage industry is enormous and makes a huge array of goods that extend into every home, restaurant, convenience store, and grocery store in America.

“That makes the [struggle against childhood obesity] much more difficult than the fight against tobacco,” Dietz said.

There is no second-hand smoke equivalent. The American public was alarmed when it learned that the cigarette smoke non-smokers breathed in airplanes, bars and restaurants was dangerous, and that no amount of second-hand smoke was safe.

“The notion that my behavior as a smoker can have an effect on you and can make you sick was critically important in accelerating people’s intolerance of smoking and their willingness to see the government take action,” said Michael Eriksen, director of the Institute of Public Health at Georgia State University.

There is no equivalent in the fight against obesity.  ”Your being obese does not affect me in the same direct way,” Eriksen said.

The best argument might be that obesity consumes enormous health care resources, driving up the cost of medical care for everyone, suggested Dr. Robert Lustig, a professor of pediatrics and director of the Weight Assessment for Teen and Child Health Program at the University of California, San Francisco. But others think that is too abstract and will never yield the same sense of personal outrage that the second-hand smoke issue created.

The role of industry is less clear. In the anti-tobacco fight, tobacco companies were painted as an enemy willing to lie and manipulate the American public for the sake of profits. In turn, the demonization of Big Tobacco — made possible by bitterly fought lawsuits and the release of thousands of company documents — cultivated a common sense of threat.

By contrast, public health advocates aren’t willing to turn food and beverage into enemies in the fight against obesity.

“With obesity (as compared to tobacco), there’s a much more nuanced relationship with industry,” said Dr. James S. Marks, director of the health group at the Robert Wood Johnson Foundation. Food and beverage manufacturers, restaurants, and grocery stores all have a vital role to play in making healthier food more widely available, he noted.

“We can’t regulate our way out of this,” said Jeff Levi, executive director of the Trust for America’s Health.  ”We need to work with industry cooperatively to help change consumers’ tastes and habits.”

Others are much less certain that the food and beverage industry can be trusted to be helpful partners.

“Some companies are making huge profits off obesity,” said Stan Dorn, a senior fellow at the Urban Institute, a public policy research center in Washington, D.C., “and I worry that people who are focused on anti-obesity strategies aren’t being tough enough on them.”

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

John Wecker

Pacific Northwest Diabetes Research Institute (PNDRI) announced today that John Wecker, PhD has been appointed president and CEO.

Dr. Wecker was most recently Global Program Leader, Vaccine Access and Delivery at PATH.

PNDRI is an independent non-profit biomedical and clinical research center that focuses on eliminating diabetes and its complications.

The Institute, which has a team of 85 physicians, scientists and technical staff, was founded in Seattle in 1956 by Dr. William Hutchinson, Sr., who also founded the Fred Hutchinson Cancer Research Center.

Before he joined PATH, Dr. Wecker worked for Boehringer Ingelheim, a global pharmaceutical company, where he led pharmaceutical product development teams and championed the company’s efforts to expand access to treatments for HIV/AIDS in the developing world.

During this time he established a program to provide medication for the prevention of mother-child transmission of HIV/AIDS, free of charge to over 120 countries around the world.

Dr. Wecker received his doctorate in Biological Psychology from the University of Rochester, Rochester, NY.

Dr. Wecker succeeds Dr. Jack Faris, who has been serving as acting CEO during the past eighteen months. Dr. Faris will remain part of the PNDRI team as a strategic advisor.

Dr. Wecker will begin at PNDRI on April 23^rd.

To learn more:

• For more information about PNDRI, visit www.pndri.org or call (206) 726-1200.

When the numbers of fecal coliform bacteria are high, the bay is closed to assure that contaminated shellfish are not marketed.

The state health agency’s Shellfish Program says this closure shows there’s more work to do to correct the pollution problems that have affected Samish Bay.

Samish Bay is currently classified as “Conditionally Approved,” because it is periodically closed due to fecal pollution when the Samish River rises quickly.

Samish Bay - Washington State Department of Ecology

The Shellfish Program will continue to collect and test water samples, and will reopen shellfish harvests when results improve. Past closures have lasted a few days.

Local and state agencies, residents, and volunteers have been working for three years to eliminate the temporary closures of Samish Bay. That would lead state health officials to change the classification to “Approved.”

State health officials say the bay could be upgraded to “Approved” if there is only one pollution closure between March 1 and June 30.

Another closure this spring would confirm that more work needs to be done to identify and correct pollution problems.

Skagit County, Skagit Conservation District, the Departments of Ecology and Agriculture, residents and volunteers are continuing to identify pollution problems and get them fixed.