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Kaiser Health News
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."
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More bureaucracy, more expense. If a doc can't look at a patient and tell if they are overweight, they shouldn't be practicing. The insurance companies shouldn't need prompting to treat obesity, it will save them money in the long run. We, as a society, have to confront our eating habits. As long as we advertise large portions of junk food constantly on the TV there is going to be a problem.
I was thinking the same thing - doctors dont need to use BMI to realize their patient is Obese. They should be able to figure that out by just looking at them.
i think the reality is that doctors are tired of telling patients to lose weight, when the patients dont ever listen...so they probably get to the point where they feel like - whats the point?
I cant even imagine how tiring it would be to be a doctor, knowing you care infinitely more about your patients well being than they do themselves...at least, it would seem that way given how little they take care of themselves or heed your advice.
I don't think I could be a doctor...i'd look a diabetic straight in the face and say "quit eating yourself to death, problem solved!"
and then id get sued into oblivion for stating the obvious.
Let the doctors quantify it and the insurers fee the snot out of it - obesity, and it's attendant ocean of ills, would end next week.
Obesity is a trillion dollar market.
No, people that are overweight are the key to stopping obesity. Stop eating so much and get some exercise. Weight Watchers points system helped a lot. The real key is to set a reasonable goal and realize that it's going to take a while to get there. It's a lifestyle change and not a quick fix.
For some BMI is a joke. I lift weights and train for figure competitions, I can assure you I am not overweight but who knows what BMI would say. Probably not an issue for me but for some bodybuilders BMI reports them as obese when clearly they are not.
Instead obesity should be based on body fat.
And yet the media and medical associations and dietitians persist in using this as standard. I had a friend who was a personal trainer and was absolutely ripped. His BMI indicated he was overweight and the doctor told him to lose weight.
What's really a disservice is how a person who is overfat but highly muscular is viewed.
BMI is a poor way to say a person is overweight or even obese now days. By using the BMI charts I am overweight but yet my Percent of Body fat is only 16% and for my age that is very good. For me to get to the top end of the BMI chart I would have to have a %PF of less than 5%.
We need to get really and use the %BF not the BMI for ratings.
I have become so disgusted with medical insurance & the price of drugs and so disillusioned with the medical care in this country that my number one priority is staying as healthy as possible. I eat a lot of veggies & fresh fruit, always walk on my breaks at work, get as much sleep as needed, take time for fun-I loathe dealing with doctors and Blue Cross and am taking responsibility for my health as much as possible.....
If they are charging smokers more for life insurance & health insurance, they need to be charging obese individuals, alchoholics, and recreational drug users more for their insurance. It has been shown that obesity is now the #1 health issue, not heart disease, not cancer, not diabetes. People need to pay for the services they receive!
Where do you draw the line???? If you have had cancer once ... you most likely will have it again. High stress job? Stroke candidate. Older women of child bearing age? High risk pregnancy alert! Hate to break it to you but most insurance premiums, when in a group setting, is based on utilization as a whole ... not in just one area (like tolerance therapy that you are in need of).
Obesity is a SYMPTOM of a problem, and does not manifest itself in all people. There are plenty of thin diabetics and thin people with heart disease. Don't kid yourself.
Symptom of what? Obesity is a huge problem--it is the cause of many leading illnesses, some fatal, in the US and the world
Whats your point? Not all smokers get lung cancer--doesn't make it good for you. Just because some obese people don't have heart attacks while some thin ones do, doesn't make fried chicken good for you
I completely agree with some of the prior comments. BMI is not a good gauge of true health. It can be very misleading in both directions. I have know super skinny people who are more unhealthy than some of the slightly overweight people who are very active but carry extra weight. BMI would show the slightly overweight person as the unhealthy 'risk' while the skinny unhealthy person as 'healthy'. There are far better markers in things like body fat percentages, cholesterol numbers and other blood work. Lifestyle plays a huge role. So, I agree counselling is a good thing to combat the root cause of the obesity or food addiction; that is only a small piece. We all need to take responsibility for our own health and not wait for the government to 'fix' the problem or cough up the money to pay for it. There are many tips and ways to exercise and eat right on a budget. People have to WANT to make the change and be willing to do the work over time.
BMI is actually meaningless.
People can be thin but still have too much fat in their body, and yet they would still not register as obese on the BMI scale. Just like with clothes, there is no one size fits all when it comes to healthcare.
BMI is simply an indicator. A person with more muscle mass may well not be overweight.
But most TeleTubbies in America lack muscle mass.
Doctors are the key to fighting obesity? Since when is someone else responsible for my weight? We have really got to stop micro-managing in our society. Individuals are responsible for making choices about their lives. I'm so tired of hearing that folks are capable of making good choices. Of course they are. But, they choose not to. Go down the aisles of your local grocery store and look at the beautiful packaging; read the list of ingredients on some of the most popular cereals or bread packages; look at how much processed food is on our shelves; compare the price of healthier foods with those that are processed and full of preservatives and sugar; eg. Velveeta cheese; sorry, but this is not cheese; or, Cheerios; this is cereal?; read the ingredients; or, better yet, Fruit Loops; no way for anyone to start their day. If we are serious about reducing obesity and promoting healthful living, we need to look at our food sources and the products that are on our shelves. We need to stop marketing junk food and make healthy food affordable for all. As for doctors, please. They know nothing about proper nutrition and refuse to accept the impact of foods on our health. It's so much easier to prescribe a pill and to cling to old medicine. I'll manage my own health thank you very much.
Actually, read the label on the cereal and put it back and walk away. We are not birds and do not have a craw for ingesting grains. Eat food that will not cause insulin spikes. It is not difficult to do.
MB,
I agreed with you right up until the "doctors know nothing about proper nutrition".
Be personally accountable? Check.
No micromanagement? Check.
Read your food labels? Check.
Make healthier choices? Check.
So far, so good, but then why turn around hold doctors accountable for something you just argued against? Doctors know plenty about nutrition, but nobody wants to listen. Everyone wants a pill or a shot or a magic wand (or Hydroxycut, or ephedra, or phinphen, or a tapeworm). Frankly, I bet your doctor is thrilled that you manage your health. More people should step up, mind their own health, and live with the consequences of their actions.
Why blame the doctor for the fact that a majority of the American population does not share your ability to successfully manage their own health or is uninterested in listening?
The American lifestyle, including 40 hours a week working sitting in front of a computer (for a lot of us) is a major contributor. Daylight savings time also limits the time you can exercise before and after work if you walk, run, hike, bike. It also limits outside time for kids after school. Finding time and money for an exercise club isn't always possible. One of the few perks my job offers is access to an olympic sized outdoor pool. It's hot where I live in summer, and that's my main form of exercise. This year they announced that they would be paving it over for a parking lot.
People are responsible for what they eat and how fit they are, not doctors or insurance companies.
I believe that people just want to eat what they like and that too often is bad/junk food. Most do not want to commit to eating healthfully: not because they don't know how but because they don't want to. And a doctor telling them isn't going to change much. I find that a lot of people want to carry on with their inactive, junk food lifestyle and then go to a doctor on a regular basis to get pills for diabetes, hypertension, high cholesterol, etc. If a pill will allow them to live that lifestlye, then their problem is solved. I agree with Peace 3229328: I am disgusted with our whole "healthcare" system and I stay away from doctors whenever possible, which is often as I feel terrific every day. And I truly believe that I feel this way because I eat a diet rich in fruits, veggies, whole grains with very little meat and no junk/processed foods. I also exercise on a regular basis and don't smoke. (By the way, you don't need a gym membership or an outdoor facility to work out. Buy a few inexpensive videos and weights and make your home your gym any time you want Everyone can find 30 minutes most days to do this!). At 58 I am healthier than a lot of people half my age. Take responsibility for your own health and quit relying on doctors, insurance companies, the government, etc. to "solve" this problem.
Sorry - if you are limiting fat and eating lots of grain you are still spiking your insulin. I too exercise and follow a high fat, low carbohydrate diet and have done so for 7 years. I too fell great - lots of USABLE zinc from red meat to keep my muscles strong.
Unfortunately you're pissin into the wind, WM.
The lifestyle of low carb/ high fat is still beyond comprehension for almost everyone in society including doctors and so called nutritional "experts."
50 years of wrong info instilled into the public has succeeded in engorging not only the US but most other developed countries.
Though I do believe that providing incentives to doctors and insurers can help, I think that treating them as the "key" is really shifting responsibility. As a society we continue to ignore the true causes of obesity because they are politically difficult to deal with. The source of the problem is not ignorance on the part of the consumers, callousness on the part of doctors and insurers, or even an overabundance of food. The source of the problem is simply that our food supply has become severely spiked with starch and sugar over the last couple of centuries. Pure and simple. All of the other factors are really just details. Honestly if the government simply taxed foods based on their glycemic indices and removed all subsidies for corn the obesity epidemic would rapidly be over. The alternative would be that the government has to specifically limit sales of foods that are high in sugar or processed starches (which is less appealing). The problem with all that is that, at least in the near term, this would cause food costs to go up and, perhaps more importantly, would deny the voting public access to their favorite foods.
Frankly, though, if you do not start with addressing the source of the problem then everything else you are doing is just hypocrisy.
I like your idea, but you seem to be "shifting responsibility" to the government, which will just fail in a different way than our current system...
I was diagnosed as pre-diabetic and am overweight. I asked my doctor to refer me to a dietician and exercise specialist (wheelchair involved); he was more than willing to help me go in the right direction. However, the insurance company told me that while they would pay for a gastric bypass, they would not pay for me to see a dietician to learn to eat better or any form of exercise advise. I was stunned: expensive surgery instead of education? Really?
Perhaps I am uninformed but I assumed that preventative care would be much cheaper than surgery and the stuff needed for diabetes.
It is possible to reverse pre-diabetes (though not always full blown type 2) by eliminating grain and sugar. You will be told that is not true, but I just came off a week long seminar with cardiologists, lipidologists, and diabetes doctors who have done so. It is hard to get support from a doctor to do this bc they often just want to give you pills and tell you to exercise more/eat less. Fat stabilizes blood sugar, and has never been proven in ANY CLINICAL STUDY to be harmful. The dietary recommendations of the last 30 years have been one huge failed experiment foisted on the American Public. If you do nothing else, please check out Gary Taubes "Why we get fat and what to do about it" and make up your own mind. You seem pretty logical and you may be surprised at the evidence.
Isn't that the most goddamn ridiculous thing you've ever heard of, Betty? I'm a physician and I get that everyday.
Too bad the studying stopped at graduation and what actually WAS learned was wrong.
Doctors know little to nothing about what fuels the human body, but if I should need stitches I'll call ya, doc.
but "teatarded" is the expert. Yeah, right.
I am and thank you;-)
Modern pill pushers need to choose enlightenment over ignorance or your extremely well marbled society will continue to swell as will, undoubtedly, your personal wealth.
And modest and completely uncapable of understanding sarcasm...quite an interesting combination. tell me, where did you acquire your vast nutritional knowledge? Certainly not school...let me guess..the internet? Ah, the bastion of the ignorant...
Nonsensical drivel. You use big words to try and impress...but your posts have no meaning. Whats a "well marbled society"? What a laughable phrase. Its just pandering for attention and screaming, "look at how smart I am!!"
No one is fooled...
BMI is not a measure of obesity; it's an indicator that someone MAY be overweight. The only way to really see if someone is obese is to check the body fat percentage. If you are a weightlifter or work out to gain muscle mass you will be considered obese using BMI as a measure. If we're going to get on the lets regulate obesity kick, like we have everything else, we better have a good measure before sticking someone in some arbitrary category. The insurance companies would love nothing more than to be able to charge even more money to clients based on bad science as long as it means more profits for them.
Any doctor who is stupid enough to believe that BMI, or insurance companies will have any positive role in fighting 'obesity' is an idiot who should have his license revoked. The single biggest threat to health in the US is insurance companies. Doctors who feel insurance companies are any kind of partner in their patients' health are crooks, or at the very least, seriously undereducated .
BMI is a measure of nothing valuable. The more stock we allow insurance companies to put in this bogus measurement invented by BIG DIET, the more we risk everyone's health and the lives.
All the doctors in the world, all the social programs in the world won't fix the problem if the people don't have personal initiative to change their habits. There are some cases where lifestyle is not the culprit in obesity, but that simply cannot be the case for the majority of people who are obese. Genetics play a role, but give me a break, 30+% of the population are not genetically doomed to be overweight!!
The vast majority of obese people lack self discipline, is it going to make a difference if a physician tells a patient that the patient is overweight? Obese people are simply not motivated to lose weight. Either they don't care or they are too lazy to research proper dietary habits and simply will not implement healthy eating and exercise into their daily lives. What might motivate some of the obese would be an increase in health premiums or better yet, a tax for being fat. Money talks. Life insurance companies charge more premium for being overweight, why shouldn't health insurance companies charge more. Let's put the burden on the fat people, why should people that take care of themselves have to bear the cost of those who don't.
Another group of people who could help fight obesity are the cops. They can quit harassing people going out and getting their exercise. My doc told me to lose weight or get diabetes. I walked, I rode my bicycle. I lost 20 lbs. in 20 days doing 1000 calories of exercise and limiting my food intake to 2000 calories a day. What did the cops do? Took my picture for riding a bicycle down the street. When I called them up and told them what a bunch of idiots they were, they didn't thank me, they put a decoy car in my walking path. I kid you not. They ride around on their fat a's in their cars and harass people out exercising. Why don't I job? Football knee injury, I can still limp and ride a bicycle though.
I am a pediatric nurse practitioner and I see kids every day on their way to obesity. But when I try, tactfully, to bring this up (using the growth charts as evidence), parents get highly offended. Daily I hear about "big bones" and large family members, etc. and starting two-month-olds on solid food because they were not "getting full." It is very frustrating and the pediatrician I work with feels the same. It is hard to talk nutrition to the parent when they brought the 18 month old in eating cheetos for breakfast.