Surgery, therapy effective against obesity; more should get both

Marianne Udow-Phillips is the director of the Center for Healthcare Research & Transformation, a nonpartisan health policy center based at the University of Michigan with a mission to promote evidence-based care delivery, improve population health and expand access to care.

In 1990, 14.1 percent of Michigan’s population was considered obese. Twenty years later, that rate was at 30.3 percent and has stayed fairly constant for the last few years. Michigan is one of the 10 “fattest” states  in the country – one of the few northern states in the top 10. This is one measure where it is not good to be in the top 10.

Obesity contributes significantly to many health issues, especially cardiovascular disease, cancer and diabetes. It is not surprising, then, that Gov. Snyder has chosen obesity as a major area of focus and a key health indicator on the Michigan Dashboard. It is essential that we understand this issue and do something about it in our state.

The issue of obesity has long been of concern to public health professionals and while there is uniform agreement that this is a national (indeed, a global) problem, what to do about it has been an issue of much greater debate. Michael Bloomberg is famous for his attempts to tax sugary beverages and ban supersized drinks while serving as New York City mayor. Snyder has promoted his “4 by 4” plan, which calls for maintaining a healthy diet, exercising, obtaining an annual physical and avoiding tobacco use and exposure. While these ideas may have merit at addressing obesity (though evidence does not generally support an annual physical exam), the causes of obesity are complex and the solutions less clear than they are for other health behavior related issues such as smoking.

The importance of this issue, combined with the lack of clarity on what to do about it, led us at Center for Healthcare Research & Transformation (CHRT) to take a look at detailed health risk assessment and claims data available to us from Blue Cross Blue Shield of Michigan to see what we could discern.

Our findings show that those who are severely obese (those with a BMI of 35 or higher) have considerably more health problems than the moderately obese (those with a BMI between 30 and 35). Severely obese individuals had many more health issues, and had average annual health care costs of $7,117 per year – 50 percent higher than costs for the moderately obese and 90 percent higher than those with a healthy weight. Those who were moderately obese were two to three times more likely to have multiple chronic conditions or serious health conditions, along with higher health care costs, compared to those with a healthy weight.

What do these findings tell us?

Well, first of all: It may be important to distinguish between levels of obesity rather than trying to develop a one size fits all approach. For those who are severely obese, it is essential that health professionals and community leaders do what we can to help them lose weight. And, for those who are moderately obese, it is essential that we do what we can to help them from progressing to become severely obese along with trying to help them to lose weight.

There is good news in our findings as well. Fifty percent of both the severely and moderately obese reported that they were actively trying to manage their weight. And, more than one-third of both the moderately and severely obese were “confident” that they could be successful.

Motivation and confidence are tremendous assets to build on. And, fortunately, we do know that there are strategies that work. Two strategies have evidence-based support: bariatric surgery and intensive behavior therapy.

Bariatric surgery is one of the only treatments that has shown the ability to reduce body weight by 20 to 60 percent. But today, in Michigan and nationally, many fewer people get bariatric surgery than are clinically eligible.

Intensive behavioral therapy (IBT) for obesity is one of the few primary care-based approaches to obesity shown to work. Indeed, the U.S. Preventive Services Task Force found that 12 to 26 sessions could produce significant reductions in weight. The evidence was strong enough for this service to be included as one of the required preventive care services (with no patient cost-sharing) in benefit plans under the Affordable Care Act. Unfortunately, there is currently no agreed upon definition or criteria for what constitutes IBT in Michigan and many people may not have access to high-quality services in this regard.

While there are many interventions related to obesity that have popular support, if we are truly going to tackle this issue and reduce both the related human suffering and health care costs, shouldn’t we focus on the things we do know work and make sure they are widely available in Michigan at high quality and reaching the population they are intended to serve? With a population that appears as motivated as those in our study, shouldn’t we all work together to give them the kind of help that has been shown to make a difference?