September 22, 2010

A healthy menu: Group Health approaches to weight-loss and obesity research

Cynthia Niver weighed 285 pounds in 2009 and was taking the maximum  dose of two different diabetes medications. Watching her mother-in-law's  terminal battle with diabetes and heart disease, she thought, "That could  be me in 30 years."

It could be many of us, says Group Health Research Institute (GHRI) Associate Investigator David  Arterburn, MD, MPH. "Unfortunately at Group Health, like the rest of the United States,  two-thirds of adults and one-third of kids are overweight," he says. Nearly one in three of us are obese and the condition doubled among American adults from 1980 to 2000, say the Centers for Disease Control and Prevention and the National Institutes of Health.

The dramatic rise might be leveling off, but with 42 percent higher health costs for the obese than people of normal weight, obesity is a national problem with an impact on Medicaid, Medicare, and private insurance.  Obesity is linked to cardiovascular disease and diabetes, some types of cancer,  joint and sleep problems, and pregnancy complications.

First Lady Michelle Obama has made fighting childhood obesity her national cause. Her message is that simple lifestyle changes—eating  better and moving more, can make a big difference in our health.

Anyone who has tried to change their diet or start an exercise plan knows it isn't easy, but that's what Cynthia Niver did at age 53, motivated by dreams of an active retirement and some unflattering photos. She lost 90 pounds in 14 months, allowing her to drop one diabetes medication and reduce the dose  of another by half. Her doctor calls her "the poster child for weight-loss  benefits."

Niver's weight-loss program, Accomplish, is a model of what might work in a larger population. Accomplish, initiated in 1988 by Group Health, has participants choose from a selection of proven  behavioral interventions. This strategy of matching evidence-based options to  individual needs is the ultimate goal of obesity research at GHRI, says Arterburn. Getting to that goal will require multidisciplinary approaches that  tackle obesity at the community, family, and individual levels.

DeAnn Cromp, MPH, focuses on how to create communities that encourage  healthy eating and physical activity. In spring 2010, Public Health-Seattle  King County received $25.5 million in federal stimulus money to reduce obesity and tobacco use. Cromp is part of a team from the GHRI Center  for Community Health and Evaluation that is assessing the process and impact of  this initiative. It includes community projects creating healthier environments, for example by making fresh fruits and vegetables available at  corner stores.

"The projects get at the root causes of obesity, and make broad changes that impact a lot of people," says Cromp. "They get local  governments, schools, and community organizations together to think about how to make their community a healthier place."

They also raise awareness. Cromp describes a project where community members contribute stories and photos to an online map of King County  that will show disparities in access to green space and recreational  facilities, which coincide with high obesity rates. The map will be used to  show policy makers how the built environment influences health. Creating it gets people involved in advocating for changes in their own neighborhoods.

Community-level strategies to combat obesity make sense in light of a  2010 study by a team that included GHRI Associate Investigator Paula Lozano, MD, MPH. Obesity and poverty go hand-in-hand, so Lozano and her team matched  U.S. Census data with electronic medical records to show that neighborhood is a risk factor for childhood obesity. It was more common where income, home  ownership, and women's educational levels were low, and the numbers of  non-white residents and single-parent households were high. This was true even taking family socioeconomic status into account. Lozano says, "This contributes to our growing knowledge on how important the environment is in determining if we are overweight."

Lozano is also working on family-based solutions to obesity.  She and pediatrician Sarah Rudnick, MD, run the Group Health Family Wellness  Program, a behavioral approach to obesity prevention for families with at least  one overweight parent and 6- to 12-year-old child. Kids and parents set exercise and dietary goals and meet regularly with health counselors to monitor progress. Making lifestyle changes is painstaking, and there's no magic wand, says Lozano. "But Group Health is well poised to move these programs forward, and has an ethical mandate to do so—increasingly, health plans will be  judged on how we take care of our children." 

Even in the best community and family environments, individuals have to do the everyday hard work of making behavioral changes and being personally accountable for the results. That starts with finding a  long-term solution that a person can stick with. GHRI Research Associate Evette Ludman, PhD, specializes in discovering personal motivations for lifestyle changesand tapping into them to create individualized health programs. She and Group Health psychiatrist and GHRI Senior Investigator Greg Simon, MD, MPH,  study depression and obesity, which often occur together. Recently, they showed  that depressed people can succeed in obesity control programs if—like anyone  else—they get involved in a weight-loss program and stay with it.

For the most severely affected, another option is weight-loss surgery such as a gastric bypass. In 2010, David Arterburn published two studies analyzing  surgery costs and benefits using Veterans Affairs records. After surgery, many obese patients discontinued medications, but among the older, predominantly male veterans, overall health costs after three years were not reduced. These findings could affect future health policy decisions, and they highlight the challenges of considering surgery, so another Arterburn project examines whether shared decision-making—a process for helping patients make more informed choices, improves the quality of treatment decisions. Cynthia Niver  participated in the Group Health study on shared decision-making for obesity surgery. She already had reservations about long-term effects, and after receiving information on surgery risks and benefits, decided against it.

Niver's progress previews the future of Group Health obesity treatment. Arterburn explains that well-designed studies can determine the most  effective weight-loss methods. The intensive methods usually tested in clinical trials are often more than most people need and too expensive for universal  application, so the next step is developing programs tailored to individual needs, identified through a personalized health risk appraisal such as Group  Health's online Health Profile tool. Informed patients then choose preferred treatments from appropriate resources.

Arterburn envisions a "stepped care approach" offering a menu of options, from advice for those who need to lose a modest amount of weight, through group counseling and behavior intervention programs, to drugs and surgery, if appropriate. And this goes beyond Group Health, he says. GHRI researchers  are active collaborators with a group of obesity researchers in the HMO  Research Network—a national consortium of research centers integrated with health care systems that are combining forces to conduct large-scale, population-based studies on the most effective ways to improve health care.

In the end, though, it comes down to each of us creating an environment in our communities and our homes that encourage a healthy lifestyle.  Cynthia  Niver's achievements were not just picking the right weight-loss methods, but making the difficult physical and mental changes, she says. She's ready for the  hard part—maintaining a healthy diet and exercise program, self-assessing and changing her routine when she starts to gain weight.

"I'm not on a diet. I'm relearning how to live the rest of my  life."

By Chris Tachibana

Paula Lozano, MD, MPH

Senior Investigator, KPWHRI; Associate Medical Director for Research and Translation & Physician, Pediatrics, Washington Permanente Medical Group

Gregory E. Simon, MD, MPH

Senior Investigator
Kaiser Permanente Washington Health Research Institute