California is in the midst of an unparalleled obesity epidemic. Poor diet and physical inactivity are the second leading causes of death and disability, resulting in nearly 30,000 deaths each year in California. The prevalence of overweight in Californians has increased from 38 percent in 1984 to 57 percent in 2003. (See Reversing the Obesity Epidemic: California’s Strategies for Action). The percentage of obesity among older adults in particular, has markedly increased nationwide. In 1991, 14.7 percent of people who were 60–69 years of age and 11.4 percent of those who were older than 70 years of age were obese. In 2000, these numbers rose to 22.9 percent and 15.5 percent, respectively, which represents increases of 56 percent and 36 percent, respectively, in less than 10 years (See Obesity in older adults: technical review and position statement of the American Society for Nutrition and NAASO, The Obesity Society).
These numbers reflect that nearly one in four older adults are considered obese. The included graph demonstrates this trend, showing that the highest percentages of obesity are among the baby boomer population, those soon to be Medicare eligible and those newly eligible (ages 50-69). As mentioned in last edition’s obesity article, this epidemic contributes to the country’s growing medical costs, with obesity-related medical expenditures estimated at $75 billion in 2004. Approximately one-half of these expenditures were financed by Medicare and Medicaid. Obesity-attributable Medicare estimates by state ranged from $15 million in Wyoming to $1.7 billion in California. (See State Level Estimates of Annual Medical Expenditures Related to Obesity)
Obesity is a risk factor for many chronic conditions, including four of the ten leading causes of death in the U.S. – coronary heart disease, type II diabetes, stroke, and several forms of cancer. It is also linked to high blood pressure, arthritis-related disabilities, increased limitations on activities of daily living (ADL), depression, sleep disorders, and mental health problems. While the obesity trend is growing particularly among the soon-to-be and newly eligible Medicare population, many state and another agency/organization programs are focused most on addressing childhood and adolescent obesity. For example, in the past year, the Governor signed many pieces of legislation, including The Healthy Schools Now Act, which bans the sale of sugary drinks and junk food at K-12 public schools. He also included $18 million in last year’s budget to get more fruits and vegetables in school cafeterias and launched the California School Garden Network, which gives grants to any school in California that wants to plant a garden on campus. To encourage children’s physical activity, California has adopted the first-ever physical education standards. The current budget includes up to $500 million for schools to purchase PE equipment and supplies, as well as $40 million in on-going funding to hire new PE instructors.
While all these programs and legislation are excellent steps towards creating a healthier California, what else is being done to address and prevent obesity among the general population and older adults in particular? Last edition’s article explored the who and why of this epidemic, highlighting how this health concern is shaped by strong social, political, economical, and environmental factors that disproportionately affect minorities, those living below the poverty line, and those with less than a high school education. With this information in mind, this article explores some of the current strategies for action and prevention underway in California with a particular focus on Medicare beneficiaries.
Current Actions and Prevention: healthy foods environment
While some groups continue to address obesity through individual education and behavior change (e.g. some of the American Obesity Association’s information on prevention), many programs, coalitions, organizations, and government agencies are also focused on broad environmental, political, institutional, and societal changes to change the environment in which obesity flourishes. For example, in addition to the Governor’s focus on childhood obesity prevention, he also recently signed the Healthy Food Purchase Program (AB 2384) to encourage the purchase of fresh fruits and vegetables in low-income communities. This legislation requires the Department of Health Services (DHS) to develop a “Healthy Food Purchase” pilot program that specifically targets the food stamp population so that they have greater access to, and consume foods that are more nutritious. His 10 point vision for a Healthy California also challenges families, business, community and government leaders to take actions in creating an environment that promotes “healthy eating, regular physical activity and responsible individual choices.”
As part of implementing this 10 point vision, the state government has organized the following actions/commitments from various influential groups:
- The new California Obesity Strategic Plan, which expands beyond government and lays out strategies for many different sectors to help create a shift to healthy eating and active living. This plan was constructed with input from a number of advisory groups and forums. The plan identifies recommendations for action for all sectors to make sustainable changes in physical activity and food environments.
- A new commitment from California Clubs of Distinction, which is the association of the fitness and racquet club industry, and the California School Board Association to work together and create a health, nutrition and exercise curriculum and programming consistent with state law and individual school Wellness Policies.
- The California Restaurant Association and Healthy Dining will encourage California restaurants to:
- Offer a selection of appealing menu items that meet recommended nutrition guidelines;
- Provide nutrition information for their healthier menu items; and,
- Clearly identify the healthier menu selections.
- The California Hospital Association will challenge all members to meet Healthy Hospitals and Health Systems guidelines by July 1, 2007. These guidelines will promote healthy and productive employees by creating a healthy environment for hospital employees and their patients.
Challenging, mandating, and in some cases having large corporate businesses choosing to opt to provide healthier food options play a crucial role in changing our current obesity-promoting environment. For example, earlier this fall, Disney announced that they will eliminate trans fats from theme park menus and licensed and promotional food products by the end of 2007. They also said that: fat should not account for more than 30% of the calories in entrees and side dishes or more than 35% of the calories in snacks; saturated fat should not account for more than 10% of the calories in food products; and sugar should not account for more than 10% of calories in entrees and side dishes or 25% of the calories in snacks. The New York City Board of Health also just passed a measure to ban the city’s roughly 20,000 restaurants from using trans fats in their cooking by July 1, 2007. Early in the spring one of the health insurance industries’ biggest HMOs, Kaiser Permanente, awarded grants totaling $4.5 million to neighborhood organizations to promote healthful eating and other issues. These are just some examples of actions that will help transform the environment within which older adults live by providing more affordable and convenient healthy food choice options.
Promoting environments for increased physical activity
In addition to these changes promoting healthy food options, another key component to addressing obesity, among the elderly in particular, is creating an environment that promotes physical activity. Data from the Centers for Disease Control and Prevention (CDC) indicate that about 28-34 percent of adults aged 65 to 74 and 35-44 percent of adults ages 75 or older are inactive. A report released from the UCLA Center for Health Policy Research also found that less than one quarter of California adults walk regularly. As physically inactive and obese older adults experience significantly higher rates of disability, chronic disease, isolation and depression, physical activity is a key component to both prevent this condition and overcome it while moving towards strong health.
The California Center for Physical Activity (CCPA), funded by the CDC, is working to facilitate the creation of enjoyable social and physical environments that enable Californians to become and stay active, thereby, reaping the benefits of a physically active lifestyle. They are organized with three main objectives: (1) to increase the proportion of the California population, age 50 and older, who engage in regular physical activity, (2) increase the proportion of employers who sponsor, and employees who engage in, regular physical activity, and (3) increase the proportion of community and neighborhood policies and environments that encourage and support walking and biking.
CCPA has formed 31 Active Aging Community Task Forces around the state and has the Walkable Neighborhoods for Seniors program. This program convenes local coalitions comprised of residents, community leaders and local government officials to address community walkability for older adults. The coalitions identify and then pursue environmental and policy solutions that will improve pedestrian safety and make it easier for older adults to walk in their communities, as well as convene local walking groups.
A review of 12 studies found that creating or enhancing access to places for physical activity (bike trails, classes as gyms or senior centers, parks, walking paths, athletic fields, walking streets without cars, neighborhood stores, etc) resulted in a 25 percent increase in the number of people exercising at least three days per week. Some additional resources on increasing physical activity and creating environments that do so, include the following:
- Emerine, D. and Feldman, E. (2005). Active living and social equity: Creating healthy communities for all residents. International City/County Management Association (ICMA). Available: www.icma.org/activeliving
- Feldman, R. Active living for older adults: management strategies for healthy and livable communities. (2003). ICMA. Item E-43140. Available: www.bookstore.icma.org
- Harris-Kojetin, L., Kiefer, K., Zimring, C. and Joseph, A. (2005). Active living by design: creating activity-enhancing residential settings. Robert Wood Johnson Foundation report 046505. Available: www.futureofaging.org
- University of Illinois at Urbana-Champaign. National aging blueprint: increasing physical activity among adults aged 50 and older. Available: www.agingblueprint.org
- U.S. Department of Health & Human Services, Administration on Aging. You Can! Steps to healthier aging. Available: www.aoa.gov/youcan
Spectrum of Prevention – Strategic action
The California Obesity Control Project (COPI) (a program of the California Department of Health Services) has and currently continues to play a major role in assessing and evaluating the obesity issue, what’s being done by a variety of organizations, city and county health departments, neighborhoods, and agencies, advising additional strategies and outlining a plan of action. Working together with the Prevention Institute’s Spectrum of Prevention model, COPI recently published Reversing the Obesity Epidemic: California’s Strategies for Action. This model demands a comprehensive multi-level public health approach to change; it outlines six levels at which action must occur for health behavior/outcomes to significantly change. These six levels are:
- Influencing policy and legislation (level six)
- Changing organizational practices (level five)
- Fostering coalitions and networks (level four)
- Educating providers (level three)
- Promoting community education (level two)
- Strengthening individual knowledge and skills (level one)
Using this six-level model, the report reaffirms the need for multi-faceted solutions, states its overarching goals and recommends promising strategies and action steps to reach those goals. Each goal is broken down into action steps in the Spectrum’s levels. Some of the key goals include:
- Increase access to physical activity options to increase rates of physical activity and decrease rates of inactivity.
- Improve access to healthy foods, particularly in schools and low-income communities, to increase consumption of fruits and vegetables, decrease consumption of high calorie, low-nutrient foods, and decrease food insecurity and hunger.
- Improve access to culturally and linguistically appropriate nutrition and physical activity information to promote life-long skills.
- Develop community-based obesity prevention strategies, particularly within diverse communities.
- Implement research projects and surveillance systems to determine effective obesity prevention strategies.
- Improve the ability of health care systems and providers to implement obesity primary prevention, early intervention, and treatment strategies, particularly in a culturally and linguistically appropriate manner.
In California, the Strategic Alliance for Healthy Food and Activity Environments works on overarching change for all age populations by shifting the debate on nutrition and physical activity away from primarily focusing on personal responsibility and individual choice to instead examining corporate and government practices and the role of the environment in shaping eating and activity behaviors. Like many of the strategies discussed above, the Strategic Alliance promotes environmental solutions and institutional and government policies and practices that support healthy eating and activity. They focus their efforts in five key sectors including: children’s environments, government, industry practices, health care system, and the media.
Obesity prevention among older adults and the greater population in general requires a multi-faceted, strategic action approach that creates on overall healthier society. The Spectrum of Prevention assures that not only are individuals and providers educated on how live a healthy lifestyle, but also and more importantly that the policies, environment, media, and social norms of our society are also in support of these lifestyles and healthy choices. For older adults, this includes convenient access to affordable, nutritious fresh foods, environments and programs that promote physical activity and community involvement (such as community gardens, school inter-generational projects, classes at senior centers, safe neighborhoods with walking paths). Inherent in such a multi-faceted approach is also specific attention given to eliminating the health disparities seen in all age groups that non-supportive and harmful environments and policies have disproportionately imposed on minority populations.