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Obesity - a public health burden reaching the crisis level
Obesity has become a public health problem that has wide-reaching clinical and tremendous economic impact on the world healthcare system in the future. Obesity is already a real threat to our society, not like Global warming which is a controversial and debated issue, as regards to its future adverse effects. What we have is a dual and parallel epidemic of type 2 diabetes and obesity; one could call it ‘diabesity’, leading to cardiovascular disease and death globally.
This epidemic requires a paradigm shift from viewing obesity as only a personal life style issue to recognizing it as a major public health concern. We need a seismic shift in our outlook for weight control now, to prevent a tsunami effect on the world health care system later. We need to have an effective intervention to mitigate a potential economic crisis.
The conventional methods of just diet and exercise programs have not been effective to control our obesity epidemic
In spite of the availability of numerous different commercial weight loss programs, diet books, and diet and fitness centers in every part of the US and Canada, the prevalence of obesity has only increased not only in the adults but also in the children and the adolescents as well.
Approximately 45% of women and 30% of men in US are attempting to lose weight, at any time. Certainly, employers and healthcare payers are searching for new strategies to combat obesity. There is not going to be a silver bullet to achieve this goal.
We have the skill, but not enough will
Lack of discipline and will power are major contributors to the obesity epidemic. To achieve any life-long weight loss and weight maintenance, there needs to be personal behavioral change for the long haul, and not just diet change. We need to promote acceptable and tolerable common sense diet and make people calorie conscious, not diet conscious.
There seems to be no lack of intelligence or information but probably not enough incentive to implement the life style changes, for most people. We have an urgent need for developing and implementing innovative, realistic and practical methods to enhance life-style interventions.
We need to retool our strategies and tactics to get better results rather than keep pounding on the idea of personal life style transformation which hasn’t produced much result in real life. We need to have initiatives to promote personal responsibility and reward for safe and healthy behavior.
Reward and penalty
 There are several initiatives being sponsored by employers and insurance companies to motivate patients to break their unhealthy habits by offering tangible rewards of cash, rebates and discounts, just like auto-insurance premium discounts being offered for safe drivers, and non-smokers paying fewer premiums for their life and health insurance. There are financial incentives for people to participate in health screenings, fitness programs or tobacco-cessation programs.
In a national survey in July 2006, 53% Americans think it is “fair” to ask people with unhealthy life styles to pay higher insurance premiums and deductibles or co-payments for their medical care, than people with healthy lifestyles. In Nov. 2003, the comparable figure was about 37%.
Management of overweight and obesity should be integrated into routine medical care. Dr. Chemplavil’s reward system to control obesity is a simple and effective program which can be a model for other incentive programs for prevention and control of chronic diseases. Even token amount of money can influence, if not manipulate their minds subconsciously and encourage them to get the will power to do what they already know.
US presidential candidate in 2008, Governor Mike Huckabee lost 110 pounds since 2003 when he was diagnosed to have diabetes and he deservedly “bragged” about it in his stump speeches. One would wonder what incentives he had for him to lose all that weight other than controlling his diabetes!
Dr. Chemplavil challenged his patients with a slogan: show me the results and I will give you the money. http://www.vascularweb.org/news/archive/archive-1.html The hype and hope of taking the challenge, the excitement of winning, acknowledgement of achievement, and the short-term pleasure - all of these contributed and resulted in the immediate monetary gain, with long-term health benefits for his patients. Even losing in their challenge may work positively for the patients- the embarrassment and humiliation can make them come back with a vengeance, to win the next time.
Some people are motivated by reward, no matter how small it may be, just like people respond to sales, attracted by cash rebates, discounts and coupons. Of course it will work only for some and not for others.
As the Dollar for Pound program rewards only for results and not just attempts, it becomes cost effective as well. It makes perfect economic sense to provide initiatives to promote personal responsibility and reward people for safe and healthy behavior, as we don’t live in an ideal world with ideal people. It is a win-win situation for all, the patients, physicians, health care payers, employers, governments and the society.
We should propose a new global c ampaign slogan for weight management - Small Rewards and Large Returns, just like Muhammad Yunus’ Grameen bank and microfinance concept.
Societal problem needs innovative solutions at the societal level
Business as usual should not be our business any more in obesity management.
We need to have a multi-prong approach for the control and management of the obesity problem at the personal and societal level, and for the long haul.
There needs to be weight clubs, not just health clubs or obesity clubs, for weight loss and weight maintenance in all the establishments where there are groups of organized people, whose body weight should be monitored, and they should be encouraged to be fit. Joining these clubs can be voluntary but establishing them should be mandatory.
The members then can institute reward systems in creative ways, even with their own pooled money, encouraging all obese people in all walks of life, to adhere to sensible eating habits and exercise to lose weight and maintain it.
We should encourage our children to acquire low fat, low sugar and low salt taste as early as possible and learn to eat slowly and do scheduled exercises at home and school, and discourage them from too much snacking.
Packaged food labeling should be changed: sugar should include all simple sugars, not just cane sugar; all packages should show the total calories in big bold letters, for the whole contents, not just for the serving size and they should have color coded boxed bar with 3 columns- each for sugar, salt and fat-Red (avoid if possible), Yellow (consume with caution), and Green (may consume without restriction).
We should teach cooking with low sugar, low salt and low fat at all culinary schools and encourage the same cooking principles in the cookbooks as well.
We should be mini-sizing all ready-to-use food and drinks, and mini- sizing plates, cups and glasses- 8 oz. serving glasses should be the standard, instead of the 12 oz. available now, and discourage all-you-can eat meals.
There should be readily accessible water fountains in all public places and free water readily available at all eating places and no free refills for soft drinks.
We need to have appropriate legislations passed at the local, state and federal levels to achieve these goals, sooner than later.
Dollar for Pound weight loss program concept - Beyond the medical office
Gifts like brand name shoes, bikes or I-Pod for children, a vacation trip to exotic places or spa treatment for the wife, set of golf clubs or plasma TV for the husband can be attractive in our homes to persuade us to lose some weight and maintain it.
Employees can have weekly or monthly get together with monitoring of body weight and periodic educational sessions on staying fit and healthy life style habits, incorporating some kind of contests to win rewards even with their own pooled contributions ,or supported by employers. Employers can in turn demand credits on health and life insurance premiums for their employees, who in turn can receive credits for their own premium payments. Of course healthy employees are benefiting from their own good health and provide better work performance and increased productivity to their employers.
Health care payers, both commercial and government agencies, also can benefit economically by implementing the reward system in health care and health maintenance. Patients and health care payers save money on medications especially in the treatment of diabetes, hypertension, high cholesterol and arthritis which are dependent on diet, exercise and obesity. Similar reward system plans can be adopted for schools, colleges, universities and for the public at large.
To sum up, the reward systems can be implemented in numerous creative ways in homes, schools, colleges, workplaces, medical practices, churches and other community centers.
Answering to the critics and skeptics
Comparing the results of the four popular diets in US, people on Atkins diet, LEARN diet, Ornish diet and Zone diet lost on an average 4.7 kilogram, 2.6 kilogram, 2.2 kilogram and 1.6 kilogram respectively for a one year period.
With pharmacotherapy, mean weight loss was 4.4 kilograms, 3.6 kilograms, 2.9 kilograms and 2.8 kilograms using Sibutramine, Phenteramine, Orlistat and Bupropion respectively, at 12 months.
From the perspective of cost, side effects, and staying in the program, Dollar for Pound program is probably superior to any diet and drug treatment programs.
Of course this was not a prospective, randomized, and placebo controlled scientific study. However, the Dollar for Pound program is a real life, simple and practical weight loss program that can be implemented in any physician’s office at negligible cost and effort, with no side effects.
The money helps Dr. Chemplavil’s patients to jump-start their weight loss and get used to a new, healthier way of life for the long haul, by developing a “dollar memory” to lose the pounds. Money probably works as a conditioned stimulus, and life style change as a conditioned response (Pavlov’s reflex).
To maintain the weight loss in any program, one needs to continue the special diet program or stay on the medication; or else the weight comes back. The cost and the adverse effects are major reasons for the high dropout rates from these programs in the long run.
There is no single cause for obesity, neither a single solution for its control. We exercise less and less but eat more and more. We are not Hunters and Gatherers any more, but surfers and shoppers on the web now. Our ‘genetic hardwiring’ and the thrifty gene theory may partially explain why our biology is naturally stacked up against us losing our body weight.
Nonetheless, we should make a conscious and deliberate effort to stay fit. Not doing so is analogous to not servicing an automobile periodically, blaming the ‘make’ of the vehicle. The more miles we put on the vehicle the less efficient it runs. After trying for the lifestyle transformation and the absolute will to change, for more than half a century, we still have the obesity problem in epidemic proportion, which is an indictment of our failure to control this major public health burden.
"Get Paid to Lose Weight" for the Public
In the Italian town of Varallo, Mayor Gianluca Buonanno is taking matters in his own hands to control the obesity problem in his town. Men will receive 50 euros for losing 9 lbs. in a month. Women will get the same amount for losing 7 lbs. If they can keep the weight off for five months, they will get an extra 200 euros.
A recent study from Dr. Eric Finkelstein at the University of North Carolina was published in the Journal of Occupational and Environmental Medicine, offering cash incentives for losing weight, and the results were encouraging. This adds weight to Dr. Chemplavil’s dollar for pound program results.
Obese and overweight adults in England could be paid to lose weight under plans being considered by the Government. The new strategy to tackle poor eating habits and sedentary lifestyles includes the suggestion that people should receive financial rewards or shopping vouchers for achieving and maintaining a healthy weight.
The £372 million strategy reiterates a target set last year to cut the proportion of overweight and obese children by 2020 to levels in 2000.
Alan Johnson, the Health Secretary, and Ed Balls, the Secretary of State for Children, Schools and Families, said that England should become the first leading nation to reverse the trend for expanding waistlines, especially among children.
An Austrian “wellness” hotel has found a novel way of making overweight guests lose weight - by making them pay more.
Skinny visitors to the Bioferienhotel Mandler's Landhaus, located in a pristine Alpine setting, can look forward to bargain deals, while tubby guests get pricier rates.
Call for future studies
To apply the principle of carrot and stick as an additional tool to control our obesity epidemic, we need to have more information as to how much money it takes and how long will it take to get the maximum results and whether the reward should be given by itself or combined with the punishment, or not getting the reward itself should be the punishment.
The aggressiveness and the outcome of these incentive programs could be different in the so called ‘healthy’ obese people and patients with other co-morbid conditions.
It is of tremendous economic implication to have future studies giving financial incentives to accomplish weight loss in patients and healthy subjects who are at high risk for developing cardiovascular diseases, and measuring the cost difference in achieving diabetes, hypertension and lipid control before and after the study, and the money saved in drug costs as well. This can be done by employers and insurance companies who have the highest stake in the cost saving of health care expenditure.
Conclusion
The Dollar for Pound weight loss program is a simple and novel program created by a community physician, after practicing for more than 25 years, who got frustrated by his inability to make his obese patients lose weight, by conventional methods of diet and exercise, to improve their diabetes, hypertension, and or hyperlipidemia.
It is quite unique in its design, implementation, financial support, and far reaching implication of the application of its results, for now and for the future, for the entire world. Any reward, and or punishment system should be added as a supplement and not a substitute, to the present conventional programs, to change personal behavior, to achieve weight loss and maintain it.
Even the token amount of money received from the physician encouraged majority of the patients to lose significant amount of their body weight. The human response to reward and punishment that we observe in childhood probably extends to our adulthood as well, and can be used in medicine by changing our behavior to improve our health in chronic diseases, and abandon our unhealthy habits.
If we can apply these principles in creative ways to the management of all high risk populations all over the world, we may be able to combat the obesity epidemic. Thus we can prevent and control diabetes and reduce cardiovascular morbidity and mortality, thereby saving millions, if not billions, of dollars and lives in the future.
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