A Hefty Burden

Rhode Island spends more than half a billion dollars annually on obesity-related health costs, and the state government picks up 64 percent of that tab. There are action plans in place to curb the obesity epidemic in Rhode Island, but are these initiatives enough to tip the scales?

Obesity’s upward trend is slowing in Rhode Island, but it’s still on the rise: 27.3 percent of the state’s adults were obese in 2013, up from 18.6 percent in 2004 and 10.1 percent in 1990. That’s according to the Robert Woods Johnson Foundation 2013 report, “The State of Obesity: Better Policies for a Healthier America.”  Nationwide, that puts Rhode Island right about in the middle, ranking thirty-first most obese. Twenty states are worse off, with adult obesity rates at or above 30 percent. Every state weighs in at more than 20 percent, but consider that in 1991, no state was above 20 percent.

“To me, it doesn’t matter where we are along that spectrum because obesity is still a major problem,” says Dr. Vincent Pera, director of the Weight Management Program at Miriam Hospital. It offers medically supervised treatment combining medical monitoring, behavior therapy, exercise instruction, calorie reduction and nutrition education. “The incidence of obesity in Rhode Island twenty-five years ago when we started this program was 10 to 14 percent, now it’s 27 percent. So I think to categorize obesity as a major health problem is not overstating it.”

When it comes to children, 17 percent of kindergartners are obese, (up from 16 percent); 17 percent of seventh graders are obese (down from 19 percent); and 11 percent of high school students are obese (same), according to the newest brief from Rhode Island Kids Count, a children’s policy and advocacy program. And the CDC says children who are overweight or obese are five times more likely to be overweight or obese as adults.

“We are encouraged that childhood obesity rates are beginning to level off and declining in some areas, but there are still far too many children and youth who are obese or overweight,” says Elizabeth Burke Bryant, executive director of RI Kids Count.

Obesity and overweight strongly contribute to the risk for other debilitating conditions like diabetes, asthma, cardiovascular disease, hypertension and high cholesterol. The Rhode Island Department of Health (RIDOH) reports that 38 percent of adults were overweight and another 26 percent were obese in 2011 — that’s nearly two-thirds of Rhode Island adults.

The report shows 48 percent of the obese and 37 percent of the overweight had hypertension, as compared with only 21 percent of those of normal or lower weight. Diabetes is less common, but is associated with severe complications such as blindness, heart disease and nerve damage. Seventeen percent of obese and 8 percent of overweight adults reported a diabetes diagnosis in 2011, as compared with only 3 percent of adults of normal weight. In addition, many kinds of cancers are associated with obesity, while other conditions, such as arthritis, are made worse by obesity.

“There are so many comorbid medical conditions that are associated with obesity. When they start to present and gang up on a person it can be debilitating,” says Pera. “The disability ranges from mild to very severe and, over time, it compounds and becomes a vicious negative cycle. The more obesity worsens and the older one gets and the less you move around, the easier it is to gain more and more weight. You end up in a position where it’s difficult to turn things around.”

The cost of obesity continues to limit the growth of the state’s economy. Businesses struggle to pay for expensive health insurance while the decreasing productivity of an unhealthy workforce compounds the problem. Individuals and families struggle with lost income due to obesity-related illness, disability and premature death.

Based on 2011 numbers, the RIDOH reports that Rhode Island spends $566 million annually on obesity-related health costs. That’s equal to $539 per year for every resident of the state. And, state government covers 64 percent of that cost, the highest proportion of any state in the country. Rhode Island spent more than $455 million just on obesity-related cases of diabetes and hypertension, the report points out. A five percent reduction in obesity would reduce that figure by more than $55 million per year. RIDOH estimates that for every dollar spent on wellness programs, companies could save $6 in medical and absenteeism costs.

Environment and culture have evolved to predispose individuals to obesity. Pera notes that while some people are genetically predisposed to obesity and others have experienced a trauma that makes being overweight a protective mechanism, there are other forces that play a much bigger role.

“When you think about what has changed in the last twenty-five years, it’s physical activity and food availability. Portions are much bigger in restaurants and people eat out more frequently. Prepackaged foods have more calories, and foods that generally have more calories are less expensive, so economics play a role. Packaging of calorie-dense high-sugar foods has changed. We didn’t used to see soda on the shelves in two-liter or bigger bottles,” he says.

Technology that makes life easier also makes us move less, from garage door openers and remote controls to electronic devices that keep us entertained and seated.

“At the turn of the century, the average adult caloric intake was 3,000 calories and there was very little obesity. People were mobile and burning calories. That has changed dramatically. For example, in the hospital we used to have to go looking for a chart. Now you sit at a computer and the chart comes to you,” he explains.

The good news among all the reports is increased awareness among patients and physicians.

“Maybe ten to fifteen years ago you very rarely heard anyone in healthcare talking about obesity, thinking about the causes of it, analyzing why we have a trend going on. It wasn’t that long ago that patients were not even weighed during medical visits. There’s more education to help physicians and healthcare providers learn how to triage patients with a weight-loss problem,” Pera says.

While Rhode Island hasn’t adopted an outright ban on sugary drinks, it is one of thirty-four states that charges sales tax on soda. Studies show that relative prices can lead to changes in consumption levels.

One area in which Rhode Island has made big strides is school food programs. They have improved dramatically thanks to a concerted partnership of government, education and Kids First, a nonprofit organization that worked to help improve nutritional and physical education environments.

“We implemented nutrition standards that are stricter than the USDA requirements and removed unhealthy foods from vending and snack shops at schools,” says Karin Wetherill, formerly of Kids First and now a consultant to both the Rhode Island Department of Education (RIDOE) and RIDOH.

“We worked closely with the education department, principals, superintendents and school committees, stressing the importance of crafting stronger policies in our schools so we could create a healthier environment for our children,” she says.

The first victory came in 2005 when the legislature passed a law requiring every school district to form a wellness committee to help guide program implementation.

Then, in 2007, Rhode Island passed a law that effectively removed all the junk foods from sale in schools, implemented gradually. That covered not only food in vending machines and snack shops, but bake sales, too. They are no longer allowed on school grounds during the school day and one hour after.

In 2009, through RIDOE regulation, schools developed even stronger nutritional standards for served meals. They required more whole grains, a greater variety and frequency of fresh fruits and vegetables and lower sodium levels. This past summer, the USDA implemented nearly identical standards for the entire nation, so you could say Rhode Island led the way.

“The food industry said kids wouldn’t eat it, but we showed them it could be done. You have to be creative and work with food service companies. We had tastings and brought chefs and farmers into the cafeteria to make it interesting and educational,” Wetherill says.

Schools have also implemented a farm-to-school movement, not just taking what’s available, but asking farmers to plant specific produce they need for their menus.

“So we’re supporting our local economy, too — instead of buying apples from Washington, we’re buying from local orchards,” Wetherill says.

RIDOH issued a five-year action plan called, “Eat Smart, Move More,” that identifies the state’s priorities and offers strategies for policy makers, organizations and professionals to make healthy eating and active living easier for adults and children. It’s intended to reduce duplication of effort and guide a statewide, coordinated response.

“Our partnerships are critical,” says Eliza Lawson, physical activity and nutrition program manager of RIDOH’s chronic disease prevention and control initiative. “Resources are low for the amount of work that needs to happen to effectively address obesity.”

The action plan presents twelve objectives and detailed strategies for reducing and preventing obesity encompassing the built environment, childcare facilities, communities, healthcare, schools, worksites and infrastructure. Objectives range from improvements in community walkability and access to recreation to ensuring all the state’s health centers integrate obesity prevention into routine primary care by the end of 2015. The full report can be downloaded from health.ri.gov.

The RI Kids Count brief also includes many recommendations. One key strategy on the front burner is increasing physical activity.

“National standards recommend 150 minutes of physical education (PE) in elementary school and 225 minutes in middle and high school. Rhode Island students are only required to have 100 minutes per week of health and PE instruction. Research shows that physical activity leads to healthier outcomes, which lead to better educational outcomes,” Burke explains.

The Kids Count report doesn’t just focus on schools: It makes recommendations for community action, such as providing safe outdoor spaces for activity and fostering community recreational activities.

“We have a chance to help overweight children improve rather than become obese. It’s an opportunity moment, a fork in the road, whether we pay enough attention to this as a state or we don’t,” Burke says.

The Skinny on Fad Diets:  What works and what doesn’t.

The upside to a fad diet is you may lose a lot of weight quickly. The downside: the loss doesn’t stick. The problem is that you need to sustain the diet’s behavioral changes for the long term, says Dr. Vincent Pera, director of the Weight Management Program at Miriam Hospital.

“Fad diets like the ‘eat like a cave man’ operate around the idea that there’s some radical change one does at the outset, which results in radical, temporary weight loss, which makes the person feel they’re making progress. But you cannot sustain that radical change, and progress slows or stops entirely,” he explains.

For someone with a relatively straightforward weight problem, a low carbohydrate/low fat approach tops Pera’s list. “South Beach offers a similar low carb/low fat approach, but they’re a bit extreme on the protein,” he says.

“If people cannot come to a medically supervised program like ours, the best place to get appropriate kinds of recommendations would be a nutritionist. They’ll help you evaluate caloric intake and offer some advice on protocols to follow to ensure proper nutrition while cutting calories,” he explains.

However, there are two popular diet programs that he feels are on solid ground nutritionally, which is the most important thing with dieting.

“Weight Watchers helps people control portion sizes and stay motivated. Jenny Craig takes it a step further with pre-portioned foods as well as individual counseling and interaction with people,” he says.

A key concern with diets not prescribed by a medical program or nutritionist is that some people have medical issues or might be on medications that affect nutritional needs, such as how much protein they can tolerate.

“People tend to underestimate how dietary change can affect things like sodium and potassium levels. You need to be careful with nutrition and factor in how changes might change kidney function or other areas,” he warns.

Bottom line: best place to start? A conversation with your doctor and/or a visit to a nutritionist.