The rate of obesity among Medicare beneficiaries more than doubled from 1987 to 2002, jumping from 11.7 percent in 1987 to 22.5 percent in 2002, according to a recent study in Health Affairs. Spending on health care for those beneficiaries also more than doubled over the same period, increasing from 9.4 percent of the program budget to 24.8 percent. This trend mirrors the national rise in the prevalence of obesity among the adult population which has doubled to 30 percent since 1980, and has increased by eight percentage points since 1990. According to Centers for Disease Control and Prevention reports, obesity also consistently ranks behind smoking as the second leading “actual cause” of death. Health care expenditures associated with obesity are estimated to be between $26-75 billion annually, or between 5 and 15 percent of total annual medical expenditures in the United States. Public insurance programs — Medicaid and Medicare — pick up a large portion of these costs. In the past two years Medicare also changed its coverage policy so as to open its doors to coverage of anti-obesity related interventions/treatments.
This article is the first of a two-part discussion on obesity. This first article discusses this growing issue with a particular focus on Medicare beneficiaries, and examines who is obese and why. Part two explores ideas and solutions of what can be done about it. While the obesity epidemic represents an enormous and complex public health issue, these two articles aim to raise awareness and continue sparking the dialogue and effective action on creating a healthier society.
Who is obese?
As mentioned above, a growing percent (60 million) of the adult population suffers from obesity. Much media attention is being given to this issue and especially to the increasing number of obese children, which has tripled to nine million since 1980 (CDC, Overweight and Obesity: Home). Governor Schwarzenegger signed several important pieces of legislation aimed at preventing and alleviating some key factors to childhood obesity among children last year and continues to actively promote such efforts and his 10 point vision for a Healthy California. Yet while these efforts are needed and necessary, not nearly as much attention has been given to the issue of obesity among older adults. As obesity is linked with some of the most serious age-associated diseases, including cardiovascular disease, stroke, diabetes, a growing list of cancers, and even Alzheimer’s disease, understanding this trend among older adults is crucial.
In 2004, the American Federation for Aging Research (AFAR) convened a conference on “The Politics of Older Adults and Obesity” to more closely examine this issue from a policy and environmental perspective. They found that the incidence of obesity among all adults rises steadily for each consecutive age group until they reach the 65-to-74 year-old bracket, when it begins to decline. Even for this group, however, prevalence has risen dramatically during the past 40 years, with the percentage of obese women rising from 23 percent to 39 percent, and men from 10 percent to 33 percent. Among people over the age 74, the percentages are lower at 20 percent of men and 25 percent of women, but still remarkably high. Past age 75, obesity is uncommon, possibly because obese people tend to die earlier, many die before the age of 70, and the oldest of older adults are more likely to be undernourished and chronically ill, rather than overweight.
Researchers at the AFAR conference found that the age group with the highest levels of obesity were actually those among the ‘leading edge baby boomers’ (ages 51-60), with the ‘late boomers’ (ages 41-50) not far behind. This is especially true for women, as the highest prevalence of obesity occurs in women in their fifties. This has far-ranging and long-term implications for Boomers’ health, especially with respect to the development of cardiovascular disease, hypertension, and diabetes. And from a policy perspective, a recent study in the Journal of the American Medical Association reports that men and women who are obese in middle age are projected to be twice as expensive to cover under Medicare compared to normal weight people. This weight and health status can have significant effects on how this country is able to pay for health care, and can also create the largest generation of obese Americans in history.
While expanding waistlines and the health challenges that come with them are epidemic across the entire U.S. population, some groups of people have been affected more seriously than others. Obesity is laden with inequity as it disproportionately affects the poor, the less educated, and people of color. According to statistics from the National Health Policy Forum at George Washington University, “In 2000, obesity was found in almost 30 percent of African Americans, slightly less than one quarter of Hispanics, and 18 percent of whites.” The same statistics show that income also has a profound effect. People close to the poverty line are 50 percent more likely to be obese than those with higher incomes. Likewise, education has an effect. Twenty-four percent of individuals who did not graduate from high school are obese, but that number drops to 19 percent of those with a high school diploma.
Why are people obese?
This question represents a complex issue and requires a multi-faceted answer. While some factors include genetics and individual food/behavior choice, these do not account for the enormity of this epidemic. In fact, at no time in history and in no other nation have people become “so fat so fast”. The most powerful and often overlooked causes to the obesity epidemic include a combination of social, economic, and political factors and institutions that shape our food choice/availability, the environment and society we live in. Eric Schlosser, author of Fast Food Nation: the dark side of the all-American meal, demonstrates how the rise in the fast food industry directly correlates with the rise in obesity. In 1970, Americans spent about $6 billion on fast food; in 2000, they spent more than $110 billion. People “spend more on fast food than on movies, books, magazines, newspapers, videos, and recorded music — combined… On any given day in the United States, about one-quarter of the adult population visits a fast food restaurant.”
Schlosser exposes how government policies, heavily influenced by meat, dairy, oil and automobile industry lobbyists/interests have and continue to support consumption of this high-additive, high-fat, high-meat, high-sugar, and high-salt diet. (Not to mention it’s a low-fiber, low vitamin, low mineral diet as well). The success and quick growth of the fast-food industry also directly correlates with shifts in policies and the government’s subsidization of the automobile through the construction of thousands of miles of freeways, boulevards, and roads.
Other public health advocates have also examined government policies and practices that promote an obesity-friendly environment and actually support the consumption of high-fat foods. For example, at the same time government campaigns aimed to ‘educate’ people on eating a healthy, balanced diet and getting plenty of exercise, the government also approved school and senior lunch programs that far exceeded its own fat and sugar recommended guidelines (The Politics of Obesity: Seven Steps to Government Action, in Politics and Public Health, R Kersh and J Morone, 2002). Federal, state, and local authorities subsidize or otherwise aid the producers of the three primary sources of fat in the typical American diet, red meat, plant oils, and dairy products. Meat and dairy products also make up two of the five main food groups in the widely used nutrition food pyramid. In addition, surplus high-fat dairy products have long been a mainstay of federal nutrition assistance programs and distribution items at food bank centers. People using these programs often have low-income and represent a disproportionate percentage of people of color.
Fast food and liquor store outlets and few, if any, grocery stores in low-income neighborhoods are also a common trend that contributes to obesity in California cities and cities across the country. For example, results of an informal survey in West Oakland, California showed 36 liquor stores with only one grocery store in an area of 26,000 residents. While some liquor stores do carry a small amount of produce, it is often both not fresh and costs 25 to over 100 percent more than it would at an average supermarket. This type of environment with a lack of fresh, affordable nutritious foods, actively encourages the consumption of highly processed, low nutrient, high-fat and sugar foods.
In a Center for Food and Justice report The Persistence of L.A.’s Grocery Store Gap, Amanda Shaffer examines how “at least a hundred years of transportation and housing policy, land availability, the evolving supermarket industry, racial prejudice and other complex, inter-connected factors have created a situation in which poor residents of the inner-city, largely minority and especially African-American, experience unequal access to supermarkets.” For example, Shaffer discusses how the housing policies after World War II facilitated both the creation of homogeneous suburbs and the flight of people, jobs and grocery stores from central cities. The Federal Housing Administration provided home mortgages with no down payments to GI’s, encouraging more people to move to the suburbs. Yet, at the same time, many of these suburban neighborhoods had white-only covenants thereby excluding African-Americans and other minorities from these communities. Loans and mortgages were also repeatedly denied to communities with small minority populations. These policies and practices of ‘red-lining’ led to the decay of many inner-city African-American and other minority communities, as businesses left, unemployment rose, and access to fresh, affordable, and nutritious foods decreased dramatically. For older adults living in such neighborhoods, access to nutritious foods can be even more limited as many may not drive and rely on buses, where they are available, for short trips.
The decline in health, growth in diseases, and increase in health care costs stemming from America’s expanding waistline, particularly among the older baby boomer generation, is staggering. Confronting the causes of this complex issue requires a multi-faceted approach and effort. Telling people to eat better and get more exercise places responsibility squarely on the individual, but fails to take broader environmental, economic, and age considerations into account. The next edition of California Medicare News will continue this discussion and explore possible strategies, ideas, solutions for addressing obesity with an emphasis on Medicare beneficiaries. As quoted from a New York Times editorial on obesity, “When it comes to eating, free will is an illusion.”