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