Ellzy 22MAR2006 Obesity Program

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Analysis of Weight and Associated Health Consequences Active Duty Staff Naval Medical Center San Diego: 

Analysis of Weight and Associated Health Consequences Active Duty Staff Naval Medical Center San Diego Naval Medical Center San Diego Population Health Department November 2005

Slide2: 

Contributors: Julie A. Neely, MD MPH CDR Cynthia J. Gantt, NC USN Ian A. Villafana, MPA Chisun S. Chun, MPH CDR Sandy M. Gharabaghli, NC USN (Ret.) The views expressed in this presentation are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.

Overview: 

Overview Introduction Burden of the Disease Disease Management Guidelines Definitions Purpose Methods Limitations Results Discussion Recommendations Resources

Burden of Disease: 

Burden of Disease Obesity is a national health crisis in the US including the DoD - Prev Med, 2001 65 % of U.S. adults (age andgt;=20 yrs) are overweight or obese. 30 % of U.S. adults are obese, andgt;60 million adults. 16 % of children (age 6-19 yrs) are overweight, andgt;9 million kid - CDC, 2005 The prevalence of Obesity rose 61% between 1991 andamp; 2001 andamp; continues to rise especially among children - JAMA, 2001

Burden of Disease: 

Burden of Disease Cost Associated With Obesity Healthcare costs, medical claims andamp; sick days increase commensurably with BMI. - Burton, 1998 36% increase in inpatient and outpatient spending 77% increase in medication utilization - AMA, 2003 US Govt (1998) Direct medical cost = $92.6 billion or 9.1% of total US medical expenditure. - Finklestein, 2003 US Navy (1993-1998) annual avoidable inpatient costs = $5,842,627 for the top 10 obesity related DRG’s. - Mil Med, 2001

Burden of Disease: 

Burden of Disease Morbidity Associated With Obesity BMI over 20 kg/m2 is associated with higher morbidity from: Hypertension Type 2 diabetes Coronary heart disease Stroke Gallbladder disease Osteoarthritis Sleep apnea Respiratory problems Psychological disorders (depression) Certain cancers: -endometrial -breast -prostate, -colon Complications of pregnancy Menstrual irregularities Hirsutism Stress incontinence

Burden of Disease: 

Burden of Disease Mortality Associated With Obesity Severe obesity decreases life expectancy 5-20 yrs. -JAMA, 2003 Mortality increases with BMI above 25 kg/m2. At BMI andgt;30 kg/m2 the rate of all cause mortality especially from CVD, increases by 50 to 100 %*. -NHLBI, 1998 *Compared to persons with BMI= 20 to-25 kg/m2

Disease Management Guidance: 

Disease Management Guidance NHLBI Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults Overweight and obese persons are targeted for intervention using a risk stratification scheme based on: Body Mass Index (BMI) Waist Circumference Co-morbid risk factors The NHLBI approach to intervention requires three components: Behavior counseling Nutrition counseling Physical fitness National Heart, Lung and Blood Institute (NHLBI)

Disease Management Guidance: 

Disease Management Guidance US Preventive Services Task Force (USPSTF) Screening for Obesity in Adults Fair to good evidence: High intensity counseling on diet, exercise andamp; behavior produced modest, sustained weight loss (3-5 kg for 1+ years) in obese adults. High-intensity is defined as more than 1 person-to-person (individual or group) session per month for at least the first 3 months to develop skills, motivate and support. Effective intervention combines nutrition and exercise counseling with behavioral strategies enabling patients to change both their eating patterns and physical activity. Initial and maintenance intervention sustains weight loss.

Definitions: 

Definitions

Definitions: 

Definitions Categorizing Disease Risk Overweight or obesity and abdominal obesity significantly increase risk* for: Type 2 diabetes, Hypertension, and CVD * relative to patients with normal BMI and waist circumference ** Increased waist circumference can be a marker for increased risk in persons of normal weight.

Definitions: 

Definitions Categorizing Disease Risk Overweight or obesity and abdominal obesity significantly increase risk* for: Type 2 diabetes, Hypertension, and CVD * relative to patients with normal BMI and waist circumference ** Increased waist circumference can be a marker for increased risk in persons of normal weight.

Purpose of NMCSD Analysis : 

Purpose of NMCSD Analysis Analyze the prevalence of overweight and obesity in the Active Duty staff at Naval Medical Center San Diego. Demonstrate the misrepresentation of risk inherent in the Navy’s current system of weight classification. Clarify the relationship between body weight, physical fitness, health care utilization patterns and health care costs.

Methods: 

Methods Specific data elements used in this analysis were from the Spring 2005, Physical Fitness Assessment (PFA) and located in the Physical Readiness Information Management System (PRIMS) data base: Physical Readiness Test (PRT) results Body Composition Analysis (BCA) results Personal Assessment of Risk Factors Questionnaire (PARFQ) positive responses

Methods Continued: 

Methods Continued PRIMS data were linked with outpatient health care services data obtained from the Military Health System Management Analysis and Reporting Tool (M2) using Microsoft Access and Excel. The NHLBI risk stratification scheme was applied to the data. Descriptive Statistics and relationships between BMI, health risk, co-morbid conditions and health care cost were determined using SPSS 11.5 andamp; Epi Info 3.3.

Limitations: 

Limitations BMI is not a completely accurate surrogate for obesity since high body weight is not always due to increased fat mass. Waist circumference is neither required by Navy instructions nor recorded on all PFA participants therefore, the estimated number of personnel at increased health risk based on BMI andgt; 25 and high waist circumference is assumed to be low.

Limitations Continued: 

Limitations Continued The process of extracting, collating and manipulating data from PRIMS and M2 may have introduced data errors. This analysis did not include either personnel who did not participate in the BCA or those who did not take the PRT. This analysis did not include either network claims data or inpatient data.

Results: 

Results Participation Rate Spring 2005 PFA 89.38% participation in the BCA 66.67% participation in PRT

Results: 

Results Distribution of Personnel by BCA 84.88% (2,806) were Within Standards 4.51% (149) were Out of Standards

Results: 

Results Distribution of Personnel by BMI 52% were Overweight (1,406) or Obese (347) 37% were Normal (1,174) or Underweight (26)

Results: 

Results Distribution of Personnel by NHLBI Risk 13.5% were at High Risk (445) 86.5% were at Normal Risk (2,510)

Results: 

Results Comparison of independent risk factors to PRT Score and BMI Gender Successful PRT completion: No statistical difference between the number of men and women (pandlt;0.22) Average BMI: No statistical difference between the average BMI of men and women (pandlt; 0.06). 1,286 female participants, mean BMI = 24.9 kg/m2 (SD=3.52) 1,659 male participants, mean BMI = 26.49 kg/m2 (SD=3.52).

Results: 

Results Comparison of independent risk factors to PRT Score and BMI Age to BMI The mean age of underweight participants was significantly younger than other BMI categories (pandlt;0.01). The mean age of obese participants was not statistically significant compared to most other BMI categories. Age to PRT The mean age of participants who failed the PRT was significantly younger than the mean age of participants in all other PRT categories (p andlt; 0.01). The mean age of participants who received an outstanding score on the PRT was significantly older than the mean age of the participants who failed the PRT (p andlt; 0.01).

Results : 

Results Comparison of the association between BMI and PRT Score Outstanding PRT Score 57.28% of the outstanding scores on the PRT were achieved by normal BMI participants. 37.31 % of normal BMI participants received either an Outstanding or an Excellent on the PRT. 14.74% of normal BMI participants received an Outstanding on the PRT; higher than any other BMI category.

Results : 

Results Comparison of the association between BMI and PRT Score PRT Failure A higher percentage (11.53%) of obese participants failed the PRT compared to participants in other BMI categories. 79.82% of the PRT failures were obese or overweight An obese participant was twice as likely to fail the PRT than a participant in any other BMI category Odds Ratio = 2.30, 95% CI = 1.79-2.95, p andlt; 0.01

Results: 

Results Comparison of the association between BMI and health care utilization pattern Visits made by PFA participants 93.38% (3,087 /3,306) of the PFA participants made 29,791 outpt visits to NMCSD between Apr 04 - June 05. 6.62% ( 219/ 3,306) of the PFA participants did not have any outpt visits at NMCSD during that time period. The average number of outpt visits for PFA participants was 9.01 The range was 1 to 128 visits per PFA participant. (SD=14.52)

Results: 

Results The average number of outpt visits DID NOT vary significantly by BMI category. pandlt;0.33 Obese participants DID NOT have a higher number of visits than participants in other BMI category. Member = PRT participant Comparison of the association between BMI and health care utilization pattern

Results: 

Results Comparison between health care cost and BMI Direct, Outpatient Cost* incurred by PFA participants Obese participants incurred significantly higher outpt costs per visit than patients with a normal BMI. pandlt;0.01 Range: $274.45 for a visit made by an obese pt $256.23 for a visit made by an overweight pt $249.91 for a visit made by a normal weight pt $243.53 for a visit made by an underweight pt $240.37 for a visit made by a pt with no BMI recorded * Cost variables are not intended to be interpreted literally but as a means to compare relative costs within the same Parent treatment facility in order to identify and investigate outliers and unusual findings. Cost was M2 variable 'Full Cost, Raw'

Results: 

Results Diagnosing Obesity ICD-9 Code 278.0X 72 staff members were coded for Obesity Apr 04 - June 05 Only 37 (10.66%) of the 347 total obese PFA participants were diagnosed with obesity 20 (1.42%) of the 1408 overweight personnel 1 (0.09%) of the 1174 normal BMI participants 15 (4.27%) of the 351 personnel who were not measured during this PFA cycle were also diagnosed with obesity.

Results: 

Results Treating Obesity Code V653 Dietary Surveillance/Counseling 103 personnel from all BMI categories had 154 total nutrition counseling visits The average number of Nutrition Counseling visits per patient seen was 1.5 35 pts were obese (55 visits, 1.57 visits/pt) 42 pts were overweight (65 visits, 1.55 visits/pt) 10 pts had a normal BMI (11 visits, 1.1 visits/pt) 16 pts had no BMI (23 visits, 1.44 visits/pt)

Results: 

Results Co-Morbid Conditions Top 20 Outpatient Primary Diagnoses Obese and overweight personnel did NOT have a unique constellation of health disorders. Lumbago and various forms of depressive and anxiety states were found equally across all BMI categories Overweight and obese personnel were diagnosed with hypertension or hyperlipidemia more often than normal and underweight active duty staff members. An overweight or obese person was more than twice as likely to be diagnosed with hypertension as a normal or underweight person OR = 2.55, 95% CI = 1.66-3.96, pandlt;0.01 An overweight or obese person was almost 3 times as likely to be diagnosed with hyperlipidemia OR = 2.85, 95% CI = 1.69-4.84, pandlt;0.01

Discussion: 

Discussion BCA misrepresented health risk associated with excess weight. BCA andamp; Health Risk The BCA method 'mis'-classified 296 personnel as within acceptable weight limits despite the fact that epidemiological evidence demonstrates that these personnel were at significantly higher risk of morbidity and mortality from chronic diseases and all cause mortality due to their excess body weight.

Discussion: 

Discussion BCA did not account for PRT performance BMI, not BCA was the single most important factor in predicting PRT failure. Roughly 80% of the PRT failing scores were attributable to overweight and obese personnel. Younger age was associated with poor PRT performance There was an inverse relationship between age and PRT performance. Younger staff members preformed poorly on the PRT while better PRT scores were achieved by older participants.

Discussion: 

Discussion Missed opportunities to interrupt weight gain occurred Many patients did not receive advice from their health care providers to lose weight - or on how to do so effectively. Only 10.7% of the obese, AD staff members were actually diagnosed with obesity Only 10.1% of the obese, AD staff members had been seen by a Nutritionist for dietary counseling.

Discussion: 

Discussion Missed opportunities to interrupt weight gain occurred NHLBI and the USPSTF states that there is fair to good evidence that high intensity counseling (greater than 2 visits per month for the first three months) produces modest sustained weight loss. The average number of Nutrition counseling visits per pt between Apr 04-June 05 was 1.5. According to the guidelines, most of these patients were inadequately treated.

Discussion: 

Discussion Higher health care cost was associated with higher BMI We found an increased average outpt healthcare cost associated with obesity. An obese PFA participant’s average cost was $24.54 higher than the average cost of an outpt visit made by a person with a normal BMI. Multiplied on a large scale, across multiple MTFs, and including all obese AD personnel not just medical staff; the additional cost associated with obese personnel is substantial.

Recommendations: 

Recommendations Use a BMI based system to classify personnel The Navy currently uses BCA to categorize personnel by weight; BCA does not accurately identify the population at risk for obesity and attendant co-morbid conditions. Using BMI andamp; NHLBI risk stratification scheme allows: Early identification of 'at risk' personnel Effective, 'early–on' evidence-based intervention Interruption of continued weight gain and associated poor performance on the PRT

Recommendations: 

Recommendations Provide concise, valuable information The Navy’s policy states that performance on the PFA is a leadership issue. - NAVADMIN180/05 Leadership at all levels must be given specific information To create andamp; enforce a culture promoting physical fitness To recognize the 'cost' associated with weight gain Health care providers must be given specific information To enable recognition and diagnosis of abnormal weight conditions To intervene by addressing weight gain and physical inactivity in the health care setting To provide goal directed, effective, evidence-based interventions targeting overweight individuals

Recommendations: 

Recommendations Improve Weight Management programs Tailor current programs to adhere to the NHLBI recommendations advocating aggressive, early identification. Focus on a regimen of behavior counseling to cause positive change in nutrition and physical activity habits. Establish goals and measures of success so that the effectiveness of interventions can be evaluated and program corrections can be implemented as needed. Evaluate return on investment for every weight management program determining whether goals were met for the targeted population at risk.

NMCSD Initiatives: 

NMCSD Initiatives Clinical Staff Education Develop and implement an all inclusive 'health care team' weight management training program based on the NHLBI, USPSTF and AMA guidelines andamp; provider training modules. Designed to: Increase awareness of BMI as a vital sign Result in weight management intervention at every encounter Integrate the entire health care team into the intervention Attain the required intensity of intervention through the coordinated utilization of the entire command’s weight management resources

NMCSD Initiatives: 

NMCSD Initiatives Weight Management Registry Develop and implement an AD Weight Management Registry Designed to: Identify and target high risk populations Establish nationally accepted goals Track program success Enable identification of ineffective programs Attain the required intensity of intervention through the coordinated utilization of the entire command’s weight management resources

References: 

References Christine H. Lindquist, Ph.D., and Robert M. Bray, Ph.D. Trends in Overweight and Physical Activity among U.S. Military Personnel, 1995–1998. Preventive Medicine. 2001;32: 57–65. Overweight and Obesity CDC Home page http://www.cdc.gov/nccdphp/dnpa/obesity/ Mokdad AH, Bowman BA, Ford ES, Vinicor F, Marks JS, Koplan JP. The continuing epidemics of obesity and diabetes in the United States. JAMA. 2001;286(10):1195–1200. Burton W.N., Chen C.Y., Schultz A.B., Edington D.W. The costs of body mass index levels in an employed population. Statistical Bulletin of the Metropolitan Life Insurance Co 1999;80[3]:8–14. American Medical Association Roadmaps for Clinical Practice. Assessment and Management of Adult Obesity: A Primer for Physicians Nov 2003

References Continued: 

References Continued Finkelstein, Fiebelkorn, and Wang, 2003. The primary data sets used to develop the spending estimates for this study included the 1998 Medical Expenditure Panel Survey (MEPS) and the 1996 and 1997 National Health Interview Surveys (NHIS). Mil Med. 2001; 166(1):1-10 (ISSN: 0026-4075) Obesity-related hospitalization costs to the U.S. Navy, 1993 JAMA Vol 289 No. 2, January 8, 2003. Years of Life Lost Due to Obesity (reference to severe obesity where severe obesity means BMI andgt;45) NHLBI- Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults. NIH Publication No.98-4083 September 1998 NAVADMIN 180/05, MSGID/GENADMIN/CNO WASHINGTON DC/N1NT/JUL//SUBJ/PHYSICAL READINESS PROGRAM//

Resources: 

Resources Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: Evidence Report. National Heart, Lung, and Blood Institute’s (NHLBI) Obesity Education Initiative, June, 1998. http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm Overweight and Obesity CDC Home page http://www.cdc.gov/nccdphp/dnpa/obesity/ USPSTF Screening for Obesity I Adults http://www.ahrq.gov/clinic/uspstf/uspsobes.htm#summary American Medical Association. Assessment and Management of Adult Obesity: A Primer for Physicians. Chicago IL: AMA; 2003. http://www.ama-assn.org/ama/pub/category/10931.html