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Primary Prevention of Obesity in
Vertically Integrated Health Reform
October 5, 2009
Beyond Universal Health Care
As our representatives draft the largest legislation of our time, they simultaneously author a promissory note to improve the health of our nation. On the table of today’s health reform debate, universal health insurance sits as the over-emphasized, monumental, legislative main course. When examining universal health care with an eye for the broader, long-term implications of such a policy, the beholder may find coverage for all Americans by itself as insubstantial in bettering American health outcomes. While essential in fulfilling Americans’ right to a healthy life, placing too heavy an emphasis on universal coverage may neglect the vital appetizers and sides of a complete and integrated health care system. Without substantial commitment to prevention, a universal system may soon find itself overburdened by the disease of obesity, and, without elimination of barriers to health care, the vital reform will not reach those who need it most.
The Senate HELP Committee reviews amendments to one of the current health reform bills. Photo courtesy of Kyle McCollom (2009).
The typical patient may associate preventative medicine with cancer screenings or cholesterol reducing drugs. These practices attempt to either catch a disease early or slow a disease’s progression and fall under the categories of secondary and tertiary preventative measures. In everyday medical care, less emphasis is placed on primary prevention – the practice of completely avoiding disease development. The National Library of Medicine defines primary prevention as health promotion, protective measures against disease, and regulation of risk factors in the environment. Under this definition, primary prevention works to improve access and eliminate barriers to healthy behavior options like healthy foods and exercise. Using the obesity epidemic as a case study, this article will examine primary prevention in health reform on the neighborhood level and the corporate level and the evidence-based savings resulting from primary prevention.
Primary Prevention as Alternative Care
The Congressional Budget Office, the government institution that measures the overall cost of legislation, declined recognition of prevention as a cost-reducing mechanism in health care in the summer of 2009. Due to the difficulty in measuring long-term outcomes of preventative measures, prevention, especially primary prevention, is viewed as an alternative reform measure and remains a controversial topic today.
The Case for Primary Prevention
While implementation of universal health care certainly carries the greatest importance in reforming health care, America’s health care system cannot be simply extended to the uninsured. Rather than expanding our sick care system, our representatives must instead implement a vertically integrated health care system that fights social determinants of illness by way of primary prevention programs. The word prevention does not automatically imply cost savings. Evidence-based prevention practices should be implemented rather than randomly selecting the most intriguing prevention methods. Beyond cost-savings, the improvement of quality of life as well as elevated productivity due to health must be considered in implementing prevention.
Case Study – Obesity and its Origins in Behavior
Attempting to differentiate between genetics and behavior as specific causes of obesity proves difficult, but the steep, upward trend in obesity from 15.0% in 1980 to 32.9% in 2004 cannot be significantly attributed to biological causes (http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overweight/overwght_adult_03.htm). This dramatic shift finds its origins in behavioral changes in eating habits and exercise decisions due to a shift in environmental influences (Jeffery et al., 2001). With arguably around one half of obesity attributable to behavioral causes, no other highly preventable disease maintains such a high prevalence rate or cost. According to the Center for Disease Control (CDC), preventing obesity would subsequently lower the prevalence rate of coronary heart disease, type 2 diabetes, hypertension, stroke and sleep apnea (http://www.cdc.gov/obesity/causes/health.html). These medical expenses due to obesity weigh in at $147 billion per year (Finkelstein et al., 2009). To put this cost in context, according to Secretary Sebelius of the U.S. Department of Health and Human Services, “ending obesity would save our healthcare system 50% more dollars than curing cancer.”
This combination of behavior-linked origins and high cost offers a strong incentive to our nation for change. This change in behavior must come in the form of altering the built environment surrounding areas at high risk for obesity. Because Americans spend the bulk of their time at home or work, primary prevention measures should be organized through the neighborhood and workforce environments.
Neighborhood-based Primary Prevention
Through the vehicle of physical exercise venues and accessible grocery stores, primary prevention of obesity on the neighborhood level counters the current environment and encourages lower energy consumption and higher energy use. According to the Commission to Build a Healthier America, “healthy environments—including safe, sanitary housing and neighborhoods with sidewalks, playgrounds and full-service supermarkets—encourage healthy behaviors and make it easier to adopt and maintain them” (McClellan et al., 2009). By implementing venues for exercise in low-income areas - areas with a strong correlation to chronic disease, low exercise levels, and increased fat consumption (Schlundt et al., 2006) – obesity may be prevented. Research links the proximity of a park to a lower risk for obesity, showing that as distance from parks increases, a decrease in visit frequency is observed (Frumkin et al., 2007).
Sidewalks enable community members to exercise regularly and feel safe walking to nearby locations. Photo retrieved from http://www.ci.highland.il.us/Public_Documents/HighlandIL_Streets/0022770A-000F8513.0/sidewalk.jpg
According to the Robert Wood Johnson Foundation, “a person’s health and likelihood of becoming sick and dying prematurely are greatly influenced by powerful social factors such as education and income and the quality of neighborhood environments. These social determinants of health can have profound effects” (McClellan et al., 2009).
Inclusion of such green spaces is an essential policy change simultaneous to universal health care. If residents of impoverished neighborhoods begin to receive primary care, their new physicians will emphasize consistent exercise. Universal health care would certainly be misleading if it were to tell “citizens to walk, jog, or bicycle when there is no safe or welcoming place to pursue these ‘life-saving’ activities” (Jackson et al.). In addition to parks, construction of sidewalks further addresses physical activity as a root cause of obesity and enables healthy behaviors like walking to work or running.
Proximity of parks can be connected to prevalence of obesity. Photo retrieved from http://www.flickr.com/photos/yourdon/2682676546/
According to the CDC, “people may make decisions based on their environment or community. For example, a person may choose not to walk to the store or to work because of a lack of sidewalks. Communities, homes, and workplaces can all influence people's health decisions. Because of this influence, it is important to create environments in these locations that make it easier to engage in physical activity and to eat a healthy diet.”
- Quote retrieved from http://www.cdc.gov/obesity/causes/index.html
To compliment increased expenditure of energy, primary prevention of obesity also works to decrease energy consumption by increasing access to healthy food options. There exists a direct connection between access to convenient, inexpensive nutrition and health outcomes. In neighborhoods lacking in health food options – called food deserts – primary prevention efforts may partner with public transportation and grocery stores to improve access to transportation and health foods (Economic Research Service, 2009). According to a Harvard School of Public Health study, higher income and better quality of health correlates with diets of increased fruit and vegetable intake (Sorensen et al., 2007). By altering the built environment with increased access to healthy food and exercise options, primary prevention in neighborhoods will reduce obesity and obesity-related diseases among the uninsured and compliment universal health insurance by lowering future costs (Sorensen et al., 2007).
According to the United States Department of Agriculture, “11.5 million people, or 4.1 percent of the total U.S. population, live in low-income areas more than 1 mile from a supermarket” (Economic Research Service, 2009).
Employer-based Primary Prevention
Photo retrieved from http://www.intel.com
Through accountability measures and employee programming, corporations can incorporate primary prevention into their business model. Because major corporations provide health insurance coverage for most of their employees, these companies find it in their best interests to keep their employees healthy, not to mention the increased productivity levels of a healthy and happy employee (Borrelli, 2009). Operating under the theory that the leading risks for disease are preventable behaviors, the model for corporate health implemented by the Intel Corporation integrates jobsite clinics with health promotion programs to lower the incidence of diabetes, depression, cardiac disease and obesity among employees. From year one to year two, 21% of the very high and high risk employee cohorts moved to a lower risk profile with decreases in all measured medical risk factors except blood sugar (Borrelli, 2009). To speak in terms preferred by businesses, Intel Corporation’s health and wellness program has provided a 3:1 return on investment in savings (Borrelli, 2009). With the private sector already contributing to prevention of disease and experiencing evidenced-based, long-term savings, it remains all the more imperative that primary prevention of disease is coupled with universal health coverage to minimize costs and improve general health outcomes.
Corporations that create incentives for exercise experience a return on investment through health cost savings. Photo retrieved from http://www.flickr.com/photos/sashawolff/3171917389/
As illustrated in America’s recent surge in obesity prevalence, behavior significantly impacts health outcomes. Regardless of how many band-aids health insurance places on the obesity epidemic, the epidemic will continue to sweep across America and increase health care costs at a drastic rate. Primary prevention, especially in regards to obesity prevention, can no longer be viewed as alternative health care. Respected academic and research institutions like the Center for Disease Control, Intel Corporation, the United States Department of Agriculture, University of Massachusetts Medical School, Robert Wood Johnson Foundation, and the Harvard School of Public Health have all produced evidence that points towards the ability of primary prevention at the neighborhood and the corporate level to both reduce disease prevalence and minimize the health costs resulting from those diseases (like obesity). Of course, not all primary prevention measures produce cost-effective health outcomes, and so we must continue to look to respected research to insure prevention efforts are well invested. As recommended in this article, such effective primary prevention methods include access to sidewalks, parks, and grocery stores in neighborhoods as well as employer-based incentives for better health.
Borrelli, A. (2009). Intel’s Health for Life health and wellness programs [PowerPoint slides]. Intel Corporation Global Health and Workforce Issues. Retrieved from http://www.allhealth.org/BriefingMaterials/WellnessAndPrevention-Alice-2-1510.ppt
Economic Research Service. (2009). Access to affordable and nutritious food: Measuring and understanding food deserts and their consequences. Washington, DC: United States Department of Agriculture.
Finkelstein, E., Trogdon, J., Cohen, J., & Dietz, W. (2009). Annual medical spending attributable to obesity: Payer-and service-specific estimates. Health Affairs, 28(5), 822-831.
Frumkin H., Nielsen T. & Hansen K. (2007). Do green areas affect health? Results from a Danish survey on the use of green areas and health indicators. Health and Place, 13, 839-850.
Hill, J., Wyatt, H., Reed, G., & Peters, J. (2003). Obesity and the environment: Where do we go from here? Science, 299(5608), 853–855.
Jackson, R., & Kochtitzky, C. (no year). Creating a health environment: The impact of the built environment on public health. Washington, DC: Centers for Disease Control and Prevention.
Jeffery, R., French, S., & Story, M. (2001). Environmental influences on eating and physical activity. Annual Review of Public Health, 23, 309–335.
McClellan, M., & Rivlin, A. (2009). Beyond health care: New directions to a healthier America. Princeton, NJ: Robert Wood Johnson Foundation Commission to Build a Healthier America.
Sorensen, G. et al. (2007). The influence of social context on changes in fruit and vegetable consumption: Results of the healthy directions studies. American Journal of Public Health, 97(7), 1216-1227.
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