Bruce Y. Lee is an associate professor of International Health at the Johns Hopkins Bloomberg School of Public Health and executive director of the Global Obesity Prevention Center
Obesity in America is a staggering public health crisis, ravaging our population, hampering the quality of life for millions and wreaking fiscal havoc along the way.
We can rightly place some blame on obvious culprits we encounter every day: super-sized drinks, processed foods and obscene portion sizes. But my time as the Executive Director of the Global Obesity Prevention Center at the Johns Hopkins Bloomberg School of Public Health has led me to a more startling and less apparent conclusion: our health-care system is keeping us from turning back obesity in America.
Each year in our country, the wide variety of obesity-related diseases (ranging from muscle and joint problems to diabetes to heart disease to cancer) result in an estimated 400,000 deaths and $190 billion in health care costs—nearly 21% of all medical spending. In the past 35 years, the prevalence of obesity jumped from 15% of the population to 35%.
An epidemic with such a high impact, in terms of lives and dollars, would seem to demand a clarion call from the White House to Congress to the halls of Health and Human Services and every health-care system, major medical society, employer and insurer. Instead, we’ve seen an approach that is heavy on concern but light on coordinated action. We have no clear plan for battling the obesity epidemic that impacts tens of millions of lives in the U.S. alone.
Any discussion during the 2016 political season that centers on health-care reform, the federal budget or the economy would be incomplete without consideration of the obesity epidemic. If we’re going to move the needle of our obesity scale and create a healthier nation, we must take a closer look at reforming the health-care system itself. I blame the health-care system for three reasons:
1. Failed Incentives
Medicare and insurance reimbursement do not provide strong enough financial incentive for physicians, clinics and hospitals to focus on obesity prevention and control. The average salary of primary care physicians, who are on the front lines on preventing obesity, is less than half that of specialists such as dermatologists ($220,942 versus $471,555, based on a 2013 compensation report). This disparity has been steadily widening since the early 1990s.
Primary care physicians also are overloaded and lack the time for obesity prevention. A 2004 American Journal of Public Health study found that primary physicians would require 7.4 hours a day (on top of everything else they need to do, such as diagnose and treat disease and handle paperwork) just to do all the preventive measures that the U.S. Preventive Services Task Force recommends. Since 2004 that list has grown.
A 2014 study published in the journal Clinical Obesity found that only half of primary care physician visits included weight discussions, and only about a third of discussions included an assessment and treatment strategy. If the health-care system is serious about obesity, then reimbursement policies need to change dramatically to promote obesity prevention and control.
2. Lack of Medical Education
Many healthcare professionals don’t have enough knowledge, training and resources to prevent and control obesity. A survey published in Obesity Research and Clinical Practice late last year showed that primary care physicians, endocrinologists, cardiologists and bariatricians had little familiarity with four major obesity guidelines that are considered the foundation for treating obesity today. Those surveyed generally didn’t understand what treatments help obese patients lose weight and get healthier.
Other studies have shown that medical school curricula don’t teach enough about topics that help prevent obesity, such as nutrition, physical activity, psychology, epidemiology, economics, and health and food marketing. Medical and residency education focus heavily on hospital care and disease treatment, rather than disease prevention. And though the health-care system has dedicated efforts toward better understanding certain biological processes behind obesity (which could lead to developing more medications), fewer efforts have sought to unearth how numerous factors around you might affect your diet, physical activity, metabolism and weight.
Obesity is a complex health problem that involves one’s biology, food access, education and myriad other factors. We know now that it’s not simply a lack of self-control. Studies have pointed to a number of different trends since 1980 that might be at fault, and the list is long, from processed food to portion sizes, from sitting too much to sleeping less, from higher stress to communities that are not walkable. We need more research to fully understand how these and other factors might fit together to properly guide healthcare professionals.
3. Limited Role of Physicians
As long as physicians only address the individual patient on the examination table, the medical profession cannot effectively prevent and treat obesity. How useful is telling patients to improve their diet and increase their physical activity if the stores in their neighborhoods don’t sell fresh fruits and vegetables and they don’t have the time to exercise or the money for a gym membership?
Major decisions about infrastructure (where to build highways, how to ensure green spaces) and consumerism (how to regulate foods and beverages) certainly impact health, but physicians and other healthcare professionals often play no role, or simply minor roles, in such decision making. Lawyers typically are involved in all of these types of decisions to provide legal guidance. Physicians, too, should play a consulting role regarding communal health issues.
What’s painfully clear through my deep examination of the obesity epidemic is that this national problem is not being met with a commensurate response from the medical and health care community. Obesity costs hundreds of billions of dollars each year and impacts millions of lives. It’s a threat to our individual well-being and to our national well-being. Insurers, medical schools, public health officials, doctors and anyone discussing health care in America must include obesity in that conversation. We know we’ll be on the right track when our health care system prioritizes prevention.
We as a country should be alarmed by the state of obesity in America and demand a comprehensive, full-throated, urgent response to this national crisis. And that effort must begin with a head-to-toe examination of the No. 1 culprit: the health-care system itself.