|Problematic Health Care Costs Other Than Obesity
As for healthcare costs, some of the problem is the high cost of overhead for the insurance companies, no doubt. All of their marketing, lobbying, corporate jets, paper pushing, etc, adds to the bottom line. Then there's the pressure to increase profits every quarter. That's another culprit along with obesity in our rising costs.
For-profit insurers also cause increased costs to hospitals, who devote time (and thus money) to trying to work with each of the different insurers to get reimbursed for their services. For example, the doctors' time spent on the phone with the insurance to get a needed procedure approved, or the time spent figuring out which drug is in the insurance plan's formulary so the patient won't have to pay the full price out of pocket.
While some of the stuff hospitals and clinics need to do to get reimbursed applies to Medicare as well as to private insurers, it's easiest when there are one set of rules (Medicare's) and not a zillion different sets of rules that you need to keep track of (one per insurance payor and plan).
Then there are the added costs from little problems that become big problems, like trips to the emergency room for uninsured patients who could have prevented the big problem by going for routine preventative care instead. Sometimes the patients pay these bills, and sometimes the hospitals get stuck with the tab when the patient can't pay. Either way, it all goes into the big pot of health care costs in the U.S.
In theory, a good bill from Congress can fix many of these things. They might be able to take away some of the ability of the insurance to set tricks and traps in the rules, making less hoops for hospitals to jump through. Hopefully, they will give us a system where all of us can get the preventative care we need, as well as trips to the doctor for little problems that come up, so we can treat them before they come expensive big problems.
But, assuming we do all of that and we do it really well, we still have the costs associated with preventable health problems caused by lifestyle (smoking, exercise, stress, sleep, and diet) and those problems are getting worse.
The Increased Costs of Increased Waistlines
I think it's overly simplifying the problem to call it "obesity." The problem is crappy lifestyles, largely crappy diets. You can be thin with a crappy diet, and you might be fat with a healthy diet. If nothing else, calling the problem "obesity" is definitely ignoring all of the thin people who eat absolute garbage. I'm sure everyone knows one of those people - the ones you hate who can eat anything and still fit in a size 4. Skinny doesn't equal healthy.
That said, obesity is easy to measure, far easier to measure than quality of diet. There's the problem that it's hard to tell what people ate. (There are two methods... disappearance data, i.e. what food was produced or imported that was presumably either eaten or thrown away, and asking people what they ate, which typically underestimates the amount eaten. How much people actually ate falls in between those numbers.) Then there's the problem of agreeing on what constitutes a good diet, which I talk about below.
When I worked in health care, my job was to go into clinics for various specialties and find out what the top diagnoses, procedures, medications, reasons for visit, etc were. Usually I'd work in primary care (internal med, family med, and pediatrics). Pediatrics was the only specialty where most of the problems are things like ear infections (i.e. not chronic, lifestyle-related problems) and an enormous chunk of the appointments were physicals, so the patients in those cases weren't even sick.
Everywhere else, you could pretty much bet that about 2/3 of the patients are coming in with chronic problems, often lifestyle related, and often more than one problem. Grown-ups occasionally go to the doctor for acute problems (ankle sprain, UTI, strep throat, what have you) but the problems you see the most are hypertension, high cholesterol, diabetes, hypothyroid, heart disease, and stuff like that. Chronic problems. Many patients have more than one of these problems.
Now, only 7.8 percent of the population had diabetes in 2008 (up from 5.3% in 1997). It's not evenly distributed among people by ethnicity/race, age, or sex. Only 2.3% of Americans 18-44 have diabetes. 18.3% of Americans 65 and up have diabetes. And I'm not sure if that is the total percent of people estimated to have diabetes, or just the percent of people who are actually diagnosed with it. I think it's just those who are diagnosed, which would then leave out the people who have it but don't know it yet.
Yet, even though "only" 7.8% of us have diabetes, that bunch of patients see the doctor far more frequently than your average healthy adult. Ditto for anyone else with a chronic problem. If you're healthy, you go in once a year for a physical (we hope) and whenever something goes wrong (like you get a UTI or need a vaccination before going on a trip). If you have a chronic condition, you go more often. That represents one way preventable lifestyle-related problems result in higher costs.
For outpatient care, doctors bill based on a few factors (unless they are doing a procedure), one of which is the complexity of medical decision making. The more complex, the more they charge. If you come in with one problem and you're not taking any meds, that's easy. If you come in with several related problems, they address them all, and you're on several meds, plus you've got some recent lab tests to take into consideration, that's more complex. That represents another way preventable lifestyle-related problems result in higher costs.
Then there are specific costs that actually ARE related to obesity. For example, requiring specialized equipment to accommodate the obese (operating tables that can handle patients over 350 lbs, or MRI machines that fit larger patients, for example). And surgeries are much more complicated when patients are obese. Time spent in the operating room is expensive. So, while obesity is an oversimplification of the problem, sometimes obesity really IS the actual issue.
What Should We Eat?
The government gives us the food pyramid as their representation of a good diet. They also come up with the "thrifty food plan" (the "healthy" diet that a person on food stamps should be able to afford), the WIC food packages given to pregnant and breastfeeding mothers and kids under 5 who are below 185% of the poverty line, and the school lunch program. I think there's little disagreement that the quality of food in school lunches is, on average, crap.
But the government isn't the only entity that tells us how to eat well. There are all of the various food companies and food industry organizations who each claim to produce healthy food. There are diet books galore that tell you to eat right for your blood type, drink tons of fresh squeezed juices, fast, limit how many carbs you eat, eat only raw food, go vegetarian, go vegan, and on and on. And there are people who follow each of these ideas. A certain percent of people are looking for a miracle food to save them, and marketers capitalize on that by selling pomegranate, acai, goji, mangosteen, hemp, etc, etc EVERYTHING.
I think that eating well comes down to a few pieces of advice I've heard from trusted sources. For babies, breastfeed! That one's easy. For the rest of us, we should go for a diet of a variety of whole foods, mostly plants. That means that if you can't identify a plant, animal, or fungi that a food came from, don't eat it. Salt and water are exceptions. It is really hard to go wrong when you are eating a variety of whole grains, nuts, beans, seeds, fruits, and vegetables. Animal products should be from animals raised on pasture. Organic food is preferable but not necessary. It's better to eat conventional fruits and vegetables than no fruits and veg at all.
My friend Hank Herrera coined the phrase "MESS:"
Food is an edible plant or animal that grows, walks or swims on the earth and its waters with no genetic engineering, no hormone-driven growth, and no synthetic chemical substances to mimic natural qualities. Over millennia human metabolism and cultures have adapted to the foods growing in every ecological niche.
Anything else is a MESS (Manufactured Edible Substitute Substance)
Any edible substance other than real food is a MESS. A MESS has genetic engineering, hormone and antibiotic residue from concentrated production, and synthetic additives. Emerging research demonstrates that human metabolism cannot handle MESSes. MESSes subvert food cultures and food sovereignty. MESSes and the processes used in their manufacture and packaging contribute to the alarming toxic load that every human being now carries.
There you go. Our health care costs are going to be a mess until we stop eating MESSes. Yet right now, we - and the government - are guilty of what Michael Pollan calls "nutritionism." That means we focus on specific nutrients and ignore what the actual food is. Diet Coke has no calories and water has no calories. If you are only comparing foods by calories, then you'd assume they are equally healthy. Obviously, they aren't.
One reason we do this is because it's non-offensive to food companies. No media outlet (TV, magazines, etc) wants to lose the lucrative ad dollars of the food companies. And for the most part, whole foods aren't advertised. I've seen an occasional billboard for avocados, oranges, and milk, but most of the ad dollars come from MESSes. If you're a news show, instead of calling out specific foods, you can call out fat, calories, carbs, and salt as the evils that are wrecking our health and avoid offending your advertisers.
An example how this plays out in DC can be found in a hearing held by the Senate Ag Committee earlier this year about child nutrition. A representative of Mars candy company spoke, patting his company on the back for coming up with a special line of candy that was made to be sold in schools to kids. It had: Less than 35% of calories from fat; Less than 10% of calories from saturated fat; and Less than 35% sugar by weight. That ignores the fact that you are still selling kids candy in school as part of their lunches. Here's what Tom Harkin said:
So if I have a bar - more than 1/3 can be sugar? I have a problem with that. When I heard that, that means that if I buy something, 1/3 of that could be sugar! Ms. Neely's heard me say many times, a 20 oz [soda] has equivalent of 15 teaspoons of sugar. I just have a problem. If 1/3 of something a child can purchase at school can be sugar - is that really a good nutritional standard? I have trouble with that. I understand the 35% fat, I understand the 10% saturated fat... I think we need to work on this.
Yet he's not questioning the idea of setting nutritional standards that the junk food companies can duck under, often without making their products healthier in any significant way. And we are teaching kids that candy's not just an occasional treat, it's something you can eat with your lunch every day.
Here's the thing. Our bodies evolved over millions of years, eating ONLY whole foods. Our bodies are VERY good at regulating how much we eat and what we eat. There is a reason we feel hungry and we feel full. There is a reason we enjoy sweets and fat. Listening to the signals our bodies send us is a good thing, a necessary thing. Yet we as a society tend to believe it's a bad thing and instead we must restrict the amount we eat and fight our bodies' natural needs. People feel guilty, even. They think they are failures.
One friend of mine insists over and over that the problem with food and obesity is education. Trust me, a fat person is WELL aware that eating makes you fat and being fat is unhealthy. They aren't stupid. They might not know that MESSes are the problem, but I'd bet you that most thin people don't know that either.
When you try to go on some sort of restrictive diet and you fight your body's needs, your body is going to (usually, at some point) win. It's going to give you signals that, at some point, compel you to meet its needs. In other words, it'll make you eat. If you eat when you're moderately hungry, you're rational enough to make a good food choice. You aren't so hungry that you don't mind taking the time to cook, or head out to a place that serves healthy food.
If you are STARVING, you shove whatever you can get into your mouth ASAP. I do this too. If I'm planning ahead, and I'm a little hungry, I'll stick some carrots in the oven for an hour, or for a quicker meal I'll steam some green beans. If I am starving, the first thing I see goes into my mouth, and if that's ice cream, then ice cream is dinner. (That's why I don't often buy pints of ice cream to keep around... instead I try to keep fruit around for when I'm starving.)
Here's where the whole foods, mostly plants, comes in. They were set up to work with your body's natural system of telling you when to eat and when to stop eating. The MESSes are incompatible with your body's signals. Your body is trying to play by the old rules it evolved to play by, and you're giving it new rules that it can't adapt to. You don't need a scientist to tell you how to eat. If you eat a variety of real foods, your body can tell you what you need.
As far as animal products go, when you get pasture-raised animal products, they are going to cost more. If you still want to eat them, the way to handle the increased cost is to eat less of them (compared to how much you would eat factory farmed products). I spoke to a nutritionist yesterday who told me she thinks meat is an important part of a healthy diet, but she thinks it's only necessary to eat about 3 oz of it every 3-4 days. That's nearly like being a vegetarian.
The truth is, I don't know how much meat is the right amount. I haven't seen any evidence that one needs meat to live and be healthy. If you get your vitamin B12 from somewhere, you can be a healthy vegan too. But if you want to eat meat, I haven't seen a good guideline from a credible source (other than the nutritionist I just spoke to) that gives an idea of how much to eat.
The US government says 4-6 oz per day (or less). My hunch is that's too much, especially when taken together with the USDA's recommendation for dairy consumption. Long story short is that we eat too much meat. By a lot. Historically, we eat much more than we did several decades ago, pre-obesity epidemic.
In 1960, the average American ate 28 lbs of chicken, 60 lbs of pork, and 65 lbs of beef. In 2006, the average person ate 87 lbs of chicken. Chicken consumption surpassed pork consumption around 1985 (per capita pork consumption slightly declined over time). Meanwhile, beef consumption rose from 1960 until the late 1970's, peaking around 95 lbs per person... Beef consumption fell since then until about 1990 and stayed more or less stable since then, around 65 lbs per person in 2006 - same as it was in 1960. Chicken consumption surpassed beef consumption in the first half of the 1990's.
If we just went back to the levels we ate in 1960 by reducing consumption of beef, pork, and chicken, we'd be better off than we are now. Especially if we reduced consumption of beef and pork (according to a study that found higher mortality linked to red meat consumption, including pork).
How does this play out for policy? A few ways. First, we need to grow healthier food. It's ridiculous to talk about changing our eating without discussing changing what we grow. If you produce crap, then how do you eat something other than crap? If every American wanted to follow the government's plans on fruit & veg consumption tomorrow, they couldn't do it. At least, not without supplementing domestically grown fruit/veg with imports.
Right now, 90% of our cropland is 4 crops: corn, soy, wheat, and hay. The corn mostly goes to animals, exports, and cars. Some goes for high fructose corn syrup, and a small bit goes to human consumption. The soy is split between animals and people. Almost all of it is crushed for oil (which we eat) and the resulting meal becomes animal feed. Most of the wheat is people food. The hay is animal food.
So, step one: Grow less animal food, particularly corn and soy. Keep the hay. Then get the animals out of the factory farms and put them on pasture. We won't be able to raise as many animals this way but THAT'S THE POINT! Plus, the animals we do raise will be healthier, AND the environment will benefit as well. Yay!
How do we do this in terms of policy? Well, banning factory farms ain't gonna happen. I say we support Louise Slaughter's bill to ban subtherapeutic antibiotics in livestock. These antibiotics make it more possible to keep animals in filthy, stressed conditions (i.e. factory farms). If they aren't allowed to use antibiotics on animals that aren't even sick, then they'll have to make other changes to reduce animal mortality. Plus, this bill will not harm any farmer who is raising animals sustainably and ethically. The bill is scientifically very sound. There's a ton of lobbying against it happening, but Obama just came out in support of it. Here are details on it - your job is to shoot off a quick email in support of the bill to your Congresscritters (all 3 of 'em).
Another great step would be to pass Tammy Baldwin's bill HR 800. Currently, if you have your land planted in federally subsidized commodities, you will be fined if you want to rotate in fruits &/or veg for a year. There's a great NYT op ed on this from a farmer who got fined for planting stuff like tomatoes and watermelon on land that was previously planted in commodities.
HR 800 will allow farmers to plant fruits & veg on land where they grow commodities. It is supported by both parties, mostly by Congresscritters from the midwest. California ag groups are lobbying against it. This means 2 things. First, we can grow more fruits & veg as a nation, because we're opening up more land to be allowed to do so. Second, we can shift some of our fruit/veg production away from California's Central Valley, which is having horrible water problems, which are resulting in decreased production and rising fruit/veg prices. Translation: More fruits/veg, cheaper fruits/veg, and better use of water (by shifting fruit/veg production to areas that get more rainfall).
The third bill that needs attention from us is the Child Nutrition Re-authorization. Here's a detailed diary I wrote up about school lunch and what needs to change. This is a bill that WILL pass this year, and the question is how good will it be.
Right now it seems that Congress WILL pass an update to the rules on which foods are allowed to be served in schools. The last time that was addressed was 1978, before we had a lot of knowledge we have now about nutrition and before obesity was even a problem. If you want to lobby for that, write your Congresscritters and ask them to co-sponsor The Child Nutrition Promotion and School Lunch Protection Act. The bill doesn't make the rules, but it directs the USDA to do so based on up to date science.
What is really frustrating is that we don't fund schools adequately, and they try to meet their educational needs by shifting costs over to the lunch program in any way they can, taking money away from feeding the kids the best food possible. They also are often overcrowded, leading to shorter lunch periods and less time to prepare food or allow kids to eat it.
Another problem is that we don't spend enough per kid per lunch ("the reimbursement rate" - the amount the federal government gives the schools for each free or reduced cost lunch eaten by a kid from a low income family... this rate dictates how much they spend on all lunches, even for the kids who pay full price). We spend slightly more than $2.50 per kid per lunch (something like $2.55?). And after you spend some of that one labor and supplies, you only spend about $1 on the food.
The French, Italians, and Japanese all spend at least double that (and they subsidize it so that the kids, even the rich ones, don't pay full price). In those countries, lunch is like a class. They are teaching the kids how to eat well, how to be social and have manners, and how to be French, Italian, or Japanese (since food is a part of their cultures).
A third problem is that schools are under intense pressure to sell as many lunches as possible. The $2.50 or so for each lunch sold must cover the incremental costs associated with that lunch, but the remainder of the money goes towards the lunch program's overhead (which often includes the school's overhead bc the school shifts as many costs as possible onto the lunch program). So, with a few cents per lunch, you need to cover all of that overhead. You have to sell a lot of lunches! And how do you do that? Serve foods the kids like, like junk food.
A fourth problem is the way that these issues all live in their own little silos in DC. When the budgets are made, one line item is health care. Another one is education. Another one is the school lunch program. And often different committees and subcommittees are the ones setting each budget.
Thus, if a healthy school lunch improves the quality of education (because well-nourished kids learn better) and reduces the cost of health care, then it's an investment not a cost to spend more on the school lunch program if that's required to make it healthier. But if the committee setting the school lunch budget doesn't get any credit for reducing health care costs because the health care budget is under another committee, then they don't really see that benefit and they aren't necessarily motivated by it. Likewise, whoever sets the school budget for education probably does not understand that they are strangling the school lunch program and contributing to the childhood obesity epidemic.
If you've made it to the bottom of this diary, then I hope you can stick with me for a few more minutes and shoot off a few emails to your Congresscritters. And, if you are interested in learning more about these topics, these are the sorts of things I address in my book Recipe for America.
The reason why I got into food policy in the first place was because of health care - much more the quality of life than the costs. It's not OK that we Americans are killing ourselves with our food. We deserve more enjoyable and less painful lives than this. We praise our nation for our freedom but if we are imprisoned in unhealthy bodies that cannot do the things we want to do, then we aren't truly free.