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6th Annual WWHF Dialogue White Paper
Obesity in Women: The Generational Impact Published: January 2013
Wisconsin Women’s Health Foundation 2503 Todd Drive, Madison, WI 53713
www.wwhf.org
608-251-1675
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OBESITY IN WOMEN: THE GENERATIONAL IMPACT WISCONSIN WOMEN’S HEALTH FOUNDATION 6TH ANNUAL DIALOGUE EVENT DATE: SEPTEMBER 12, 2012 EVENT LOCATION: MADISON, WISCONSIN
TABLE OF CONTENTS About the WWHF ................................................................................................. 2 About the Dialogue ............................................................................................. 2 Event Moderator ................................................................................................. 3 Panelists .............................................................................................................. 3 Background Information ....................................................................................... 4 Dialogue Discussion & Questions to Panelists ............................................... 5-12 Additional Resources ......................................................................................... 13 Sponsors ............................................................................................................ 14
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About the Wisconsin Women’s Health Foundation
The Wisconsin Women’s Health Foundation (WWHF) is a 501(c)(3) nonprofit that helps women
and their families reach their healthiest potential. The WWHF specializes in health education
and outreach with the goal of equipping women to become advocates for their own health.
WWHF programs address major causes of morbidity and mortality for Wisconsin women. The
organization’s goals are to:
Reach all Wisconsin women with the information, opportunities and support they need to
be healthy;
Encourage women to become advocates for their own health; and
Improve the overall quality of life for women and their families.
The WWHF provides programs and conducts forums that focus on education, prevention, and
early detection of the greatest threats to women’s health: cancer, cardiovascular disease,
domestic abuse, mental illness, osteoporosis, and tobacco and alcohol use.
About the Dialogue
The WWHF Annual Dialogue event is held each fall and focuses on a current women’s health
topic. The event provides an opportunity for dynamic discussion of complex issues related to
the health of Wisconsin families. Past Dialogue topics have included healthcare reform, mental
health parity, and the economics of smoking. We discuss recent research and findings,
challenges in clinical and community-based interventions, and potential ways different
stakeholders can get involved in finding solutions.
The Dialogue is led by a moderator and a multi-disciplinary panel of experts. Panelists represent
a variety of perspectives looking at the issue through different lenses. The event begins with
each panelist giving a brief presentation. Following these prepared statements, the moderator
asks follow-up questions and fields questions from the audience. Panelists close the event with
summary statements focusing on ways to move forward together.
Video from the 2012 Dialogue is available at http://www.youtube.com/user/WIWomensHealth.
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Moderator
Laurel W. Rice, MD Chair, Obstetrics and Gynecology Faculty, University of Wisconsin School of Medicine and Public Health Madison, WI Dr. Laurel Rice, Chair of Obstetrics and Gynecology at the University of
Wisconsin School of Medicine and Public Health, served as moderator at the
2012 dialogue.
Dr. Rice is nationally recognized as an expert in the care of women with
gynecologic malignancies and she serves in leadership positions of many
national organizations including the Society of Gynecologic Oncology, the
Council of University Chairs in Obstetrics and Gynecology and the American
Gynecologic Obstetrics Society. Recently, she was appointed as Director of the
Division of Gynecologic Oncology, at the American Board of Obstetrics and
Gynecology. Dr. Rice serves as an Associate Editor of The Journal of
Gynecologic Oncology. She is a passionate leader in efforts to improve women’s health in Wisconsin and
around the country.
Panelists
On September 12, 2012, the Wisconsin Women’s Health Foundation held their 6th Annual Dialogue at the
Concourse Hotel in Madison. The event featured a panel of five speakers from across the country. Each
speaker’s area of expertise highlighted different aspects of the obesity epidemic culminating in an
informative, multifaceted dialogue.
Michael J. O’Grady, PhD
President
West Health Policy Center, Washington DC
Catherine Spong, MD
Branch Chief
National Institute of Child Health & Human Development, Bethesda, MD
Chanel Tyler, MD
Assistant Professor
UW-Madison Department of Obstetrics & Gynecology, Madison, WI
Michelle Rimer, MS, MPH, RD, LDN
Director, Solmaz Institute on Obesity
Lenoir Rhyne University, Hickory, NC
Susan Latton
Obesity Prevention Program Coordinator
State of Wisconsin - Department of Health Services, Madison, WI
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Background Information1
The obesity epidemic in the United States has
grown at a staggering rate and, as shown in the
maps to the left, obesity rates are not showing
signs of slowing down.2 If the trend continues on
its current path, the national obesity rate will be
44% or more by 2030.
The Midwest consistently fares poorly in national
rankings on obesity rates. In Wisconsin, 27.7% of
adults were obese in 2011 and the predicted
obesity rate for the year 2030 is 56.3%.
Current estimates of medical costs of adult obesity
in the United States range from $147 billion to
$210 billion per year. In Wisconsin alone, obesity
will cost almost 5 million in new diagnoses of
serious conditions for women and their families
including: type 2 diabetes, coronary heart disease,
stroke, hypertension, arthritis, cancer and many
more.
Obesity must be addressed through partnerships
that combine the strengths of the public, private
and non-profit sectors to help women. If we are
successful in slowing and reversing the obesity
trend, we would see significant rewards. For
example, if Wisconsin residents’ BMIs were
reduced by 5%, our state could prevent disease
and death and save nearly $12 billion in
healthcare costs by 2030.
Note on terminology: Overweight and obesity ranges are
determined by using weight and height to calculate a number
called the "body mass index" (BMI). BMI correlates with
amount of body fat. An adult who has a BMI between 25 and
29.9 is considered overweight. An adult who has a BMI of 30
or higher is considered obese.
1 Data from: http://www.healthyamericans.org /reports/obesity2012/?stateid=WI 2 Graphics from: http://www.cdc.gov/obesity/data/adult.html
Percent of Obese (BMI > 30) in U.S. Adults,
1990 to 20102
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Michael J O’Grady, PhD President West Health Policy Center Washington DC
Dr. O’Grady is a veteran health policy expert with 24 years of experience working in
Congress and the Department of Health and Human Services. His research has
focused on the intersection between scientific development and health economics
with particular concentration on obesity in the United States. His comments at the
2012 Dialogue highlighted how trends in obesity over the past fifty years have
impacted the economy and which interventions have demonstrated cost-effective
results.
Rapid Increase in Obesity Rates
Since the 1960s, the percent of overweight Americans has risen slightly from 31% to 34%. In contrast,
the percentage of the population that is obese has grown rapidly, increasing from 13% to 35% in the last
five decades.
Gender-Based Projections
Figure 1 shows projections of obesity rates for men and women through the year 2028. Researchers calculated optimistic and pessimistic projections for future obesity rates in the US. The results showed that between 45% and 53% of the population could be obese in 15 years if current trends are not reversed. The optimistic projection for women assumes the gender-specific slower rate of increase seen since 2000. This Illustrates that progress is possible and interventions have the potential to make a significant difference. Economics of Obesity There is a clear link between increased rates of obesity and
increased medical spending in the U.S. Medical costs
related to obesity have risen to nearly $150 billion per year.
3 Specifically, prescription drug costs are impacted most by
obesity-related healthcare spending. As shown in Figure 2
to the right, in 2008, there was a 15.2% increase in use and
cost of prescription drugs for obese patients.
Cost Effective Interventions
Pharmaceutical
Surgical4
School/Community based interventions
Workplace
3 Finkelstien E, Trogdon J, Cohen J, Dietz W. Annual Medical Spending Attributable to Obesity: Payer and Service-Specific Estimates. Health Affairs 28, no. 5 (2009) w822-831. 4 Cost saving found for individuals who already have obesity-related disorders and a BMI over 50.
Figure 1 - Projections of Obesity Under
Optimistic & Pessimistic Scenarios
Figure 2 - Increased Spending Associated with
Being Obese: Percentage Increase by Payer and Service (in 2008 dollars)
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Catherine Spong, MD
Branch Chief
National Institute of Child Health & Human Development
Bethesda, MD
Dr. Spong is board certified in maternal-fetal medicine and obstetrics and
gynecology. She is currently the program scientist for the Maternal Fetal Medicine
Units Network and the Branch Chief for the National Institute of Child Health &
Human Development. Her presentation at the Dialogue discussed the impact of
obesity on women’s health and stressed the complexity of this health issue for
women and their families. Dr. Spong highlighted the changes in lifestyle that
contribute to obesity, such as technology, portion sizes, and fast food caloric content.
National Trends
Shifts in technology, social norms, and portion sizes have led to a costly and unhealthy trajectory of
obesity in the United States. Computers and video games have dramatically changed child and adult
lifestyles, becoming increasingly sedentary. Portion sizes have increased substantially since the 1950’s.
For example, a Burger King hamburger has nearly doubled in size since 1954. These factors are among
the causes of a radical shift in body weight in the last 20 years. In 1996, states with the highest obesity
rates were at 15%-19%; 15 years later, the highest rates nearly doubled to 30%. Over 60% of US adult
women are overweight and one-third of overweight adult women are obese.
Morbidity of Obesity
While it seemed unthinkable a decade ago,
obesity has recently overtaken smoking as the
leading risk for morbidity. As shown in Figure 3,
as obesity rates have increased, so has the loss of
quality-adjusted life years. Morbidity of obesity is
associated with numerous health risks. Specifically
for women, gynecologic implications include:
Infertility
Menstrual Irregularities
Ovulation Problems
Reproductive Cancers
Metabolic Syndrome
General health implications include:
Hypertension
Type II Diabetes
Coronary Heart Disease
Depression
Reversing the Trends
If women reduced their weight by just 5-7%, they could see results including lower blood pressure,
improved cholesterol levels, and reduced risk of developing diabetes. It is critical to offer preventive
interventions specific to patient needs during childhood, pregnancy, and menopause. Because obesity is
such a complex issue, treatments must be multidisciplinary and culturally appropriate. Diverse
perspectives and multi-disciplinary collaboration will be vital as the medical and research communities
develop new options for treatment and prevention of obesity.
Figure 3: Comparison of Quality-Adjusted Life Years Lost for Smoking and Obesity, 1993 to 2007.
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Chanel Tyler, MD
Assistant Professor
University Wisconsin - Madison Department of Obstetrics & Gynecology
Madison, WI
Dr. Tyler is an assistant professor at University of Wisconsin-Madison as well as a
PhD candidate in the UW-Madison School of Medicine and Public Health
Endocrinology & Reproductive Physiology program. She spoke about the obstetric
health risks for obese women, the complications clinicians may face when treating
obese patients, and possible adverse birth outcomes resulting from obesity.
Adverse Birth Outcomes
Obesity is related to increased risks for serious perinatal conditions and adverse birth outcomes. Obese
women are less likely to carry their pregnancies to term and often suffer more complications:
Gestational diabetes
Gestational hypertension
Preeclampsia
Stillbirth
Post-term pregnancy
Operative Delivery
Diminished Clinical Accuracy
Dr. Tyler explained how obesity results in diminished clinical accuracy. For example, the quality of
images viewed via ultrasound are impacted by excess fat. Ultrasound images from a woman with a
healthy-weight BMI have visualization rates as high as 90%. In comparison, ultrasounds on morbidly
obese women yield images with visualization rates at only 63%. Inability to complete a successful
ultrasound poses a serious risk for the unborn baby because clinicians are less able to anticipate health
complications such as heart defects.
Clinicians’ ability to administer anesthesia safely is impacted by obesity. Obese patients receiving
regional anesthesia can have difficult veins, impalpable vertebral spines, and are unable to curve the
lumbar spine. General anesthesia administered to overweight or obese patients has rapid desaturation on
induction, meaning that there is a risk of regurgitation, difficult intubation and difficult ventilation.
Long-term Women’s Health Outcomes
Excess gestational weight gain during pregnancy can lead to long-term health implications for women and
their children. Maternal obesity can cause a baby to be born overweight and increase the child’s risk for
diabetes, hypertension, cardiovascular disease, cancer or premature fatality. Risks for women include:
Postpartum weight retention
Long-term weight gain
Excess body fat
Sleep apnea
Pre-diabetes/diabetes
Coronary heart disease
Maternal Mortality
18% of obstetric causes for maternal deaths are related to obesity.
80% of anesthesia-related maternal
deaths are impacted by obesity.
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Michelle Rimer, MS, MPH, RD, LDN
Director, Solmaz Institute on Obesity
Lenoir Rhyne University, Hickory, NC
Ms. Rimer has a decade of experience in the prevention and treatment of obesity;
She currently works as the director of the Solmaz Institute focusing on treatment of
obesity in the family-setting. In her presentation, Rimer focused on socioeconomic
and environmental factors of obesity and related social and family issues. She
discussed the ways women are specifically affected, highlighting the examples from
her obesity clinic in North Carolina.
Socioeconomic Factors
According to Rimer, the broader epidemic that we are facing is one of poor nutrition and inactivity.
Families living in impoverished areas are impacted the most; low household income and poverty are
associated with a higher average BMI. The maps below in Figure 4 show the correlation between low-
income areas and areas with high rates of obesity.
Built Environment
The types of built environments, or man-made spaces in neighborhoods and cities, that are frequently
seen in low-income areas make physical activity difficult for many families. Many communities have
incomplete streets, are neither bike- nor walk-friendly, and are unsafe. Many families have limited access
to recreational facilities, parks, and safe outdoor spaces. The built environment in many communities is
impacting social activities that families have access to and leads to increased sedentary behaviors.
Family Dynamics
Parental obesity is one of the strongest risk factors for childhood obesity. A mother’s role is intrinsically
linked to her family’s eating habits. Children’s food preferences, especially daughters, are often strongly
correlated with their mother’s food decisions. Mothers provide genes and the family environment including
parenting style, food availability, and frequency of physical activities. For these reasons targeting mothers
as family health leaders in family based interventions is vital in improving family habits. It is vital we
support mothers in modeling healthy behaviors, creating opportunities for children to make healthy food
and physical activity choices, and making healthy eating and exercise behaviors a family affair.
Figure 4: County-level poverty and obesity rates, 2008.
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Susan Latton
Obesity Prevention Program Coordinator
Wisconsin Department of Health Services
Madison, WI
Ms. Latton has 20 years of experience working with community-based coalitions and
national partners to improve key health indicators through policy, system and environmental
changes. She works with the Nutrition, Physical Activity and Obesity Prevention Program at
the Wisconsin Department of Health Services, who in turn supports more than 50
community coalitions who are implementing population health-focused strategies. Her
presentation at the Dialogue highlighted two Wisconsin communities, funded through the
Centers for Disease Control and Prevention’s, Communities Putting Prevention to Work
initiative, that are making significant strides to assure that the healthy choice is the easy
choice through-out their county.
Building Healthy Communities
Latton stressed the importance of using promising and evidence-based
multidisciplinary obesity-prevention strategies that target a large
number of people with frequent exposure in a comprehensive manner.
Figure 5 shows examples of progressive steps that can be taken in
schools and communities to achieve maximum public health impact.
Community interventions can also take place in other settings including
early child care and education, community environments, worksites,
and healthcare facilities.
Successful Community-Based Interventions
LaCrosse County 5
The La Crosse County Healthy Living Collaboration developed a strategic plan that prioritized active commuting
and physical activity to address growing obesity rates. To make it easier and safer for community members of all
ages and abilities to be active, the Collaboration focused on improving the built environment, by encouraging the
adoption of Complete Streets at the county, village and city level. Complete Streets ensure that future road projects
consistently take into account the needs of all users, and provide dedicated space for walking, bicycling and people
with mobility challenges. The Safe Routes to School programs that encourage children and youth to walk and
bicycle to and from school. Another initiative, Footsteps to Health, was developed to help residents eat more fruits
and vegetables by providing free education on how to pick, store, and prepare seasonal produce.
Wood County 6
Get Active Wood County is a hub of local obesity prevention initiatives working together to create community
change. The Wood County Health Department convened local businesses, schools and non-profit organizations to
plan and create a healthier county through programs that increase access to healthy foods and create more
opportunities for physical activity. For example, 22 child care sites have adopted improved nutrition and physical
activity policies, planted gardens and incorporated gardening classes into their curriculum. All six Wood County
public school districts developed school wellness committees, healthier vending machine options, gardens,
greenhouses and increased physical activity. The Health Department collaborated with Farmer’s Markets to assure
that Food Share recipients had access to the array of healthy, local produce by allowing them to utilize their
Electronic Benefit Transfer (EBT) cards. The disability community in Wood County helped developed an extensive
garden that now supports and distributes over 75 Community Supported Agriculture (CSA) shares at worksites
around the county.
5 http://www.cdc.gov/CommunitiesPuttingPreventiontoWork/communities/profiles/obesity-wi_lacrosse-county.htm 6 http://getactive.co.wood.wi.us/
Figure 5: Progression of steps to maximize public
health impact in schools.
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Dialogue Discussion
Following their prepared presentations, Dialogue
panelists responded to questions from the moderator
and the audience. Three major themes emerged
through the discussion and were re-emphasized by
multiple panelists.
Challenges of Preventing & Treating Obesity in Low-Income Communities
Tyler:
We should not penalize women who are unable to access grocery stores with fruits and vegetables. We
need to address more than one issue and more than one group of people.
Rimer:
It is possible to make multiple healthy meals on a Food Stamp budget, but those meals can take up to 19
hours of preparation because of the ingredients included (dry beans, lentils, etc.). With more women
working outside the home, most actually spend less than 6 hours a week preparing meals in their home.
Spong:
A larger change is required. We need to think about what foods people consider to be “good” – what is
rewarding and satisfying. It’s more than just having access; it’s truly wanting that access and then utilizing
it. We need to find ways to make the easy choice be the healthy choice.
Latton:
All women face a bombardment of environmental pressures to consume too much and in both rural and
urban communities, they often lack access to affordable and healthy foods; there is tremendous pressure
to over-consume.
Despite our agricultural roots, only about 2-3% of Wisconsin cropland is used to produce fruits and
vegetables. The Wood County Farm-to-School program is an example of a local intervention that is
focusing on building a healthier local food system by linking local growers to local schools in a strategy
that is win-win, improving nutrition and supporting small, local farmers.
There are initiatives to introduce healthy foods to food-desert communities. For example, some
communities have successfully collaborated with convenience stores to provide fruits and vegetables and
have sent trucks into the food-deserts with fresh produce for sale.
If schools and child care centers provide healthy food and beverages for children, the children learn about
the healthy habits and bring them home to the parents.
O’Grady:
School lunch and breakfast support has been implemented for many years now, but it is more of a food
welfare program than a public health initiative. Children should be getting a good meal at school,
particularly the more vulnerable low-income population. If schools can mobilize and make sure that
children are getting two healthy meals while at school, at least one target population will be reached.
Discussion Topics and Major Themes:
1. Challenges of preventing & treating obesity in
low-income communities
2. Reproductive health and obesity
3. Economics of obesity
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Reproductive Health and Obesity
Spong:
Obesity interventions for pregnancy should begin before a woman actually becomes pregnant and
education about the risks of excessive weight gain during pregnancy need to be discussed with patients.
There has been a 70% increase in the proportion of women who are obese at the beginning of pregnancy
in the last two decades. 25% of reproductive-age women are overweight and an additional 30% are
obese.
Obesity contributes to infertility, menstrual irregularities, ovulation problems, and reproductive cancers.
Tyler:
Being a healthy weight needs to be a priority prior to pregnancy. This is a message that needs to be
consistent between clinicians in pediatric offices, family practice offices, nurse practitioners, midwives,
and OB/GYNs.
Infertility rates are higher in women that are obese. The healthier you are overall, the better pregnancy
outcome you’re going to have.
Prevalence of large for gestational age infants is almost 4 times as high among the morbidly obese as
those with normal BMIs.
Things can be done to alter pregnancy trajectories. There has been an increase in pre-conceptual
counseling with overweight women. Women are told how their weight will impact their pregnancy and the
possible complications if the extra weight is not addressed; it could impact their child’s long term health.
Just a 10% weight reduction can go a long way in improving pregnancy outcomes and that is achievable
with small steps. Women can decrease their need for expensive reproductive technology when weight
loss leads to increased ovulation.
Rimer:
Parental obesity is one of the strongest risk factors for childhood obesity, due to both genetic and lifestyle
influences.
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Economics of Obesity
O’Grady:
There is a policy gap that fails to recognize the long-term economic benefits of programs that treat and prevent obesity. With better tools, policy makers will have more information to more accurately assess obesity interventions.
In the U.S. commercial insurance market, a cost-effective intervention is one that provides the equivalent of an additional quality year of life at a cost of under $100,000. This results in a heightened concern and sensitivity about taking on tough standards. We need more research on the relative cost-effectiveness of obesity interventions so any available funding and resources are directed toward the programs and interventions that will have the most impact.
Examining data from workplace wellness programs showed they are cost-effective and they produce measurable improvements in employee health.
If the distribution of body weight continues to change at the average annual rates, then the projected
prevalence of obesity and health care spending per adult in 2020 will increase by 71%.
Obesity-related health issues are the leading cause of employee absenteeism. Annually, $153 billion in lost productivity is linked to obesity.
Spong:
The World Bank has estimated the cost of obesity in the US at 12% of the National Health Care budget.
Rimer:
Workplace wellness programs can effectively reduce health care costs. It is important that these initiatives
are integrated into the corporate wellness culture and are available to everyone. Availability to all helps
avoid the stigmatism regarding who is participating and who is not.
As employers integrate more wellness activities into the health care design they will get more for their
money. People want to work at a place where there is a healthy corporate wellness culture. It attracts
good workers and keeps people at a company.
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Additional Resources
WWHF – http://www.wwhf.org
View full Dialogue presentations – http://www.slideshare.net/WIWomensHealth
Listen to the full Dialogue – http://www.youtube.com/user/WIWomensHealth
CDC on obesity – http://www.cdc.gov/obesity/
CBO on obesity – http://www.cbo.gov/publication/21772
Michael O’Grady’s Assessing the Economics of Obesity and Obesity Interventions – http://ogradyhp.com/yahoo_site_admin/assets/docs/Obesity_Paper_3-15-12_OGrady__Capretta.8282606.pdf
National Institute of Child Health and Human Development on obesity -
http://www.nichd.nih.gov/health/topics/obesity/Pages/default.aspx
Solmaz Institute for Obesity - http://solmaz.lr.edu/
Wisconsin Department of Health Services on obesity - http://www.dhs.wisconsin.gov/health/physicalactivity/index.htm
Committee Members
Thank you to all the committee members of the WWHF 6
th Annual Dialogue. Your support is greatly
appreciated.
Cynthie K. Anderson, MD, MPH, FACOG Director, Obstetrics & Gynecology Resident Continuity Clinic Assistant Clinical Professor UW School of Medicine and Public Health
Tara LaRowe, PhD Assistant Scientist Department of Family Medicine University of Wisconsin-Madison Laurel Rice, MD (Dialogue Moderator)
Chair, UW Department of Obstetrics & Gynecology UW School of Medicine and Public Health Sue Richards, RN Parish Nurse Wisconsin Women’s Health Foundation Susie Swenson, RD, CD Health Educator Access Community Health Centers
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Sponsors
Thank you to all the sponsors of the WWHF 6
th Annual Dialogue. Your support is greatly appreciated.
Group Health Cooperative
Summit Credit Union
UW-Madison Department of Obstetrics & Gynecology
YMCA of Dane County
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