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What is Obesity?
Obesity is a disease that affects nearly
one-third of the adult American population (approximately 60 million). The
number of overweight and obese Americans has continued to increase since
1960, a trend that is not slowing down. Today, 64.5 percent of adult
Americans (about 127 million) are categorized as being overweight or
obese. Each year, obesity causes at least 300,000 excess deaths in the
U.S., and healthcare costs of American adults with obesity amount to
approximately $100 billion.
Obesity is the
second leading cause of unnecessary deaths.
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Despite its toll taken in death
and disability, obesity does not receive the attention it deserves from
government, the health care profession or the insurance industry.
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Research is severely limited by
a shortage of funds.
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Inadequate insurance coverage
limits access to treatment.
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Discrimination and mistreatment
of persons with obesity is widespread and often considered socially
acceptable.
Did
You Know?
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Obesity is a chronic disease
with a strong familial component.
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Obesity increases one's risk of
developing conditions such as high blood pressure, diabetes (type 2),
heart disease, stroke, gallbladder disease and cancer of the breast,
prostate and colon.
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Health insurance providers
rarely pay for treatment of obesity despite its serious effects on
health.
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The tendency toward obesity is
fostered by our environment: lack of physical activity combined with
high-calorie, low-cost foods.
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If maintained, even weight
losses as small as 10 percent of body weight can improve one's health.
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The National Institutes of
Health annually spends less than 1.0 percent of its budget on obesity
research.
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Persons with obesity are
victims of employment and other discrimination, and are penalized for
their condition despite many federal and state laws and policies.
Obesity - A Global
Epidemic
The prevalence of overweight and
obesity is increasing worldwide at an alarming rate in both developing and
developed countries. Environmental and behavioral changes brought about by
economic development, modernization, and urbanization have been linked to
the rise in global obesity. Obesity is increasing in children and adults,
and true health consequences may become fully apparent in the near future.
Social Structure
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Developed countries have high
obesity rates, food deprivation is unusual, and physical activity levels
have decreased greatly. Lower income households are reported to feature
diets composed of foods that tend to be high in calories and fat -
contributors to overweight and obesity - since vegetables, fruits and
whole grain cereals are more expensive.
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Developing countries have lower
obesity rates, particularly in areas of lower SES populations. People
who live in these areas are limited in their ability to provide enough
food, have little access to public transportation and engage in moderate
to heavy manual labor.
General Trends
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In many developing countries,
obesity co-exists with under-nutrition – a Body Mass Index (BMI) less
than 18.5.
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In economically advanced
regions of developing countries, prevalence rates of obesity may be as
high as in industrialized countries.
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Globally, women generally have
higher rates of obesity than men do, although men may have higher rates
of overweight.
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Prevalence of obesity in
children and adolescents is on the rise in both developed and developing
regions.
Obesity in the U.S.
Obesity is a complex,
multi-factorial chronic disease involving environmental (social and
cultural), genetic, physiologic, metabolic, behavioral and psychological
components. It is the second leading cause of preventable death in the
U.S.
Overweight and obesity are part
of the U.S. Department of Health and Human Services' health agenda that
have steadily moved away from their established targets for improvement.
Today, public health leaders recognize obesity as a "neglected public
health problem." This fact sheet will demonstrate the impact of overweight
and obesity on millions of Americans of all ages and both genders.
Overall Prevalence
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Approximately 127 million
adults in the U.S. are overweight, 60 million obese, and 9 million
severely obese.
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Body Mass Index (BMI) is a
measurement tool used to determine excess body weight. Overweight is
defined as a BMI of 25 or more, obesity is 30 or more, and severe
obesity is 40 or more.
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The number of adults who are
overweight or obese has continued to increase. Currently, 64.5 percent
of U.S. adults, age 20 years and older, are overweight and 30.5 percent
are obese. Severe obesity prevalence is now 4.7 percent, up from 2.9
percent reported in the 1988 - 1994 National Health and Nutrition
Examination Survey (NHANES) by the Centers for Disease Control and
Prevention (CDC).
Health and Social Impact
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Obesity increases the risk of
illness from about 30 serious medical conditions.
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Obesity is associated with
increases in deaths from all-causes.
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Earlier onset of
obesity-related diseases, such as type 2 diabetes, are being reported in
children and adolescents with obesity.
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Individuals with obesity are at
higher risk for impaired mobility.
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Overweight or obese individuals
experience social stigmatization and discrimination in employment and
academic situations.
Obesity in Minority Populations
Overweight and obesity in the
U.S. occur at higher rates in racial / ethnic minority populations such as
African American and Hispanic Americans, compared with White Americans.
Asian-Americans have a relatively low prevalence for obesity. Women and
persons of low socioeconomic status within minority populations appear to
particularly be affected by overweight and obesity. Cultural factors that
influence dietary and exercise behaviors are reported to play a major role
in the development of excess weight in minority groups.
Prevalence
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The prevalence of overweight
(Body Mass Index (BMI) of 25 or more) and obesity (BMI of 30 or more)
increased over the last decade across racial / ethnic groups, as shown
in Table 1.
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Mexican American and black
(non-Hispanic) adults in the U.S. are considerably more overweight and
obese than white (non-Hispanic) adults.
Health Disparities
Diabetes
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Diabetes has been reported to
occur at a rate of 16 to 26 percent in Hispanic Americans and black
Americans, aged 45 to 74, compared with 12 percent in whites
(non-Hispanic) of the same age.
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Higher BMI predicts the risk
for type 2 diabetes in Pima Indians. Type 2 diabetes affects about half
of the Pima people.
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Among 15 American Indian tribes
studied in Oklahoma, 77 percent of adults screened for diabetes are
reported to be obese.
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Among Mexican Americans,
obesity and type 2 diabetes are both increasing, unlike other risk
factors of cardiovascular disease including smoking and blood pressure,
which are declining.
Cancer
Heart Disease
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Among African Americans, the
high prevalence of obesity and obesity-related conditions such as
hypertension and type 2 diabetes, are factors reported to contribute to
their high death rate from coronary heart disease.
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In a study of older Hispanics,
with an average age of 80, obesity was found to be a risk factor for
developing coronary artery disease.
Hypertension
Behavioral Risk Factors Diet & Exercise
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Cultural factors related to
dietary choices, physical activity, and acceptance of excess weight
among African Americans and other racial-ethnic groups, appear to play a
role in interfering with weight loss efforts.
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Sedentary life style, which can
contribute to the development of obesity, has been reported by 44 to 60
percent of Native American men and 40 to 65 percent of women.
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African Americans and whites
report that they exercise less as they get older, however, African
American women of all ages report participating in less regular exercise
than white women.
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African American men, age 45
and older, report less regular exercise than white women.
Women and Obesity
Obesity plays a significant role
in causing poor health in women, negatively affecting quality of life and
shortening quantity of life. More than half of adult U.S. women are
overweight, and more than one-third are obese. The life expectancy of
women in the U.S. is approaching 80 years of age, and more women than ever
are expected to turn 65 in the second decade of the new millennium.
Prevention and early treatment of obesity are crucial to ensuring a
healthy population of women of all ages.
Prevalence
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For women, ages 20 to 74, 62
percent are overweight (Body Mass Index (BMI) of 25 or more) and about
half of that population (34 percent) is obese (BMI of 30 or more).
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Middle-age women are at a
particularly high risk of becoming obese. The prevalence of obesity
among middle-age women (ages 35 to 64) has increased at a minimum of 2
percentage points per year over a 40-year time period from 1960 to 2000.
Table 4 indicates prevalence changes in obesity (BMI of 30 or more)
between 1960 and 2000 for U.S. women in various middle-age groups.
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Low-income women in minority
populations appear most likely to be overweight.
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Obesity appears to have a
strong inverse relationship with SES (obesity increases as income level
decreases) among women in developed societies such as the U.S.
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A direct association has been
found between body weight and deaths from all-causes in women, ages 30
to 55.
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Among U.S. adults, black
(non-Hispanic) women have the highest prevalence of overweight (78
percent) and obesity (50.8 percent).
Obesity in Youth
Diabetes, hypertension and other obesity-related chronic diseases that are
prevalent among adults have now become more common in youngsters. The
percentage of children and adolescents who are overweight and obese is now
higher than ever before. Poor dietary habits and inactivity are reported
to contribute to the increase of obesity in youth.
Today's youth are considered the most inactive generation in history
caused in part by reductions in school physical education programs and
unavailable or unsafe community recreational facilities. In the U.S., only
the state of Illinois requires daily physical education for students in
grades K to 12.
This fact sheet outlines many
factors related to obesity in youth that make it the major health care
challenge for the 21st century.
Overweight and Obesity Defined
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Overweight and obesity for
children and adolescents are defined respectively as being at or above
the 85th and 95th percentile of Body Mass Index (BMI).
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Some researchers refer to the
95th percentile as overweight and other as obesity. The Centers for
Disease Control and Prevention (CDC), which provides national
statistical data for weight status of American youth, avoids using the
word "obesity," and identifies every child and adolescent above the 85th
percentile as "overweight."
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Bariatric Surgery Specialists use
the 95th percentile as criteria for obesity because it:
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corresponds to a BMI of 30
which is obesity in adults. The 85th percentile corresponds to a BMI
of 25, adult overweight.
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is recommended as a marker
for when children and adolescents should have an in-depth medical
assessment.
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identifies children that are
very likely to have obesity persist into adulthood.
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is associated with elevated
blood pressure and lipids in older adolescents, and increases their
risk of diseases.
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is a criteria for more
aggressive treatment.
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is a criteria in clinical
trials of childhood obesity treatments.
Health Effects of Obesity
Persons with obesity are at risk
of developing one or more serious medical conditions, which can cause poor
health and premature death. Obesity is associated with more than 30
medical conditions, and scientific evidence has established a strong
relationship with at least 15 of those conditions. Preliminary data also
show the impact of obesity on various other conditions. Weight loss of
about 10% of body weight, for persons with overweight or obesity, can
improve some obesity-related medical conditions including diabetes and
hypertension.
Arthritis, Osteoarthritis
(OA), Rheumatoid Arthritis (RA), Cancers,
Breast Cancer, Cancers of the Esophagus and Gastric Cardia, Colorectal
Cancer, Endometrial Cancer (EC), Renal Cell Cancer, Birth Defects,
Cardiovascular Disease (CVD), Carpal Tunnel Syndrome (CTS), Chronic Venous
Insufficiency (CVI), Daytime Sleepiness, Deep Vein Thrombosis (DVT),
Diabetes (Type 2), End Stage Renal Disease (ESRD), Gallbladder Disease,
Gout, Heat Disorders, Hypertension, Impaired Immune Response, Impaired
Respiratory Function, Infections Following Wounds, Infertility, Liver
Disease, Low Back Pain, Obstetric and Gynecologic Complications, Pain,
Pancreatitis, Sleep Apnea, Stroke, Surgical Complications, Urinary Stress
Incontinence, Other:
Obesity Treatment
A statistic frequently used about
obesity treatment is that 95 percent of people who lose weight gain it all
back. That statistic, based on a small study from 1959, is no longer
valid. Much has changed in the way of obesity treatment since then.
Thousands of people have succeeded in losing weight and keeping it off --
an encouraging fact for many that are discouraged by outdated information.
There are several different types of effective treatment options to manage
weight including: dietary therapy, physical activity, behavior therapy,
drug therapy, combined therapy and surgery.
Weight loss of about 10 percent
of excess body weight is proven to benefit health by reducing many
obesity-related risk factors. Recommendations for treatment are now
focusing on 10 percent weight loss to help patients with long-term
maintenance of weight loss. Health professionals including physicians,
nutritionists, exercise physiologists, psychologists and bariatric
surgeons help persons with overweight and obesity to determine the most
appropriate treatment.
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Assessment of Weight
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Dietary Therapy
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Physical Activity
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Behavior Therapy
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Drug Therapy
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Combined Therapy
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Surgery
Obesity Research
In the last four decades of
obesity research, progress has been made in identifying causes and
treatments. Research has provided a greater understanding of obesity
as a chronic disease caused by a complex interaction of genetic,
metabolic, behavioral, psychological and environmental (social and
cultural) factors. Despite the advances in research, however,
children, adolescents and adults are continuing to become overweight
and obese in record high numbers. Due to the complexity of obesity,
more research is needed in a variety of areas particularly in
prevention to control the spread of this epidemic.
Funding Inequities
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Public research funding for
obesity is appallingly low given that it is a major public health
crisis.
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The National Institutes of
Health (NIH) has a budget of more than $15.6 billion and is the
largest public funder of medical research. In setting the priorities
of its budget, the NIH has virtually neglected obesity research.
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Obesity-related medical
conditions such as diabetes and hypertension, receive far greater
funding than the causative condition itself, as shown in Figure 1.
Poor diet and inactivity, which contribute to obesity, is reported
to be the second leading cause of preventable death in the U.S. Yet
AIDS, another cause of preventable death, receives over 10 times
more research funding than obesity.
Obesity and Health Insurance Many insurance plans
do not provide reimbursement for weight loss treatment. According to
many practitioners, few private insurance indemnity plans or managed
care organizations appear to cover the costs of obesity treatment
regardless of whether the service is a medically supervised program of
weight reduction or maintenance, nutrition counseling, surgery or a
pharmaceutical product. The countless number of available insurance
plans and ever changing policies have made it difficult to assess the
extent to which obesity treatment and prevention services are covered
by third party insurers. More data and better tracking is necessary to
determine the health needs of persons with obesity.
Insurance Coverage Trends
Obesity, Medicaid and Medicare
Medicaid does not cover obesity, and under Medicare, hospital and
physician services for obesity are clearly excluded. Medicaid is a
government program that provides health insurance to qualified individuals
whose income level is below a certain point. Recipients of Medicaid are
primarily women and children who are poor and members of minority groups.
Given the high prevalence of obesity among those populations, it could be
presumed that many Medicaid recipients are likely to have obesity.
Medicare provides health insurance coverage to elderly citizens and
disabled Americans who qualify by meeting criteria of the Social Security
Administration (SSA) and completing a two-year waiting period.
Medicaid
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In 1990, Congress enacted the
Omnibus Budget Reconciliation Act (OBRA), which funds state programs to
provide pharmaceutical products to Medicaid recipients.
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A State may choose to exclude
or restrict drugs or classes of drugs, or their medical uses for certain
purposes. A State choosing to include outpatient drugs within its
Medicaid program must cover, for their medically accepted indications,
all Food and Drug Administration (FDA) approved prescription drugs of
manufacturers that have entered into drug rebate agreements, with a few
limited exceptions.
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Exceptions include drugs when
used for: anorexia, weight loss or weight gain; to promote
fertility; for cosmetic purposes or hair growth; for the symptomatic
relief of cough and colds; or to promote smoking cessation.
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As a result of OBRA, the
Department of Health and Human Services ordered states to cover Viagra
for the treatment of erectile dysfunction while continuing to exclude
anti-obesity agents.
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Nine states cover anti-obesity
pharmaceutical products including Alaska, California, Kentucky, Montana,
North Carolina, Oregon, Rhode Island, Washington and Wisconsin.
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One state, Arizona, covers
products by specific managed health care plan.
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In 23 states, there is no
specific language regarding coverage under Medicaid.
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In 29 states, anti-obesity
products are specifically excluded in state Medicaid programs.
Medicare
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The Medicare Coverage Manual
defines obesity and the justification for certain treatment coverage by
stating that:
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Obesity itself cannot be
considered an illness. The immediate cause is a caloric intake, which
is persistently higher than caloric output.
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Program payment may not be
made for treatment of obesity alone since this treatment is not
reasonable and necessary for the diagnosis or treatment of an illness
or injury.
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However, although obesity is
not in itself an illness, it may be caused by illnesses such as
hypothyroidism, Cushing's disease, and hypothalamic lesions. In
addition, obesity can aggravate a number of cardiac and respiratory
diseases as well as diabetes and hypertension. Therefore, services in
connection with the treatment of obesity are covered when such
services are an integral and necessary part of a course of treatment
for one of those illnesses.
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Medicare’s limited coverage of
obesity is difficult to understand when considering that it does cover
services such as inpatient and outpatient alcohol detoxification and
rehabilitation, inpatient and outpatient drug rehabilitation, and
services for sexual impotence. It also covers chemical aversion therapy
for the treatment of alcoholism even though the FDA has not approved the
drugs commonly used in chemical aversion therapy for this application.
Gastric Bypass Surgery
Surgery for the treatment of obesity is covered on a limited basis.
According to the Medicare Coverage Manual:
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it is medically appropriate
for the individual to have such surgery.
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the surgery is to correct an
illness, which caused the obesity or was aggravated by the obesity.
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