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Our Nation’s Health Is Heading In The Wrong Direction

Hang around medical folks and politicians long enough and you will inevitably hear that we have the greatest health care in the world. And while that may be true for some, it is not true for all. Simply stated, when it comes to our health. We aren’t getting the job done.

The sad reality is that we now have evidence we are failing in two important measures of health care for our nation: high blood pressure and obesity which together have a huge impact on our health outcomes and deaths over time.

Two recent online reports (here and here) and an editorial in JAMA—formerly the Journal of the American Medical Association—look carefully at the trends over time in the population frequency of obesity, and the trends in control of high blood pressure. Both are important, and both represent indicators of what we can expect in the future when it comes to the frequency and impact of serious illnesses such as heart disease, stroke, diabetes and cancer.

What the researchers report should be of concern to all of us. The studies—both from the Centers for Disease Control and Prevention (CDC)—show that we are actually doing worse in controlling high blood pressure more recently than we were in the past, and the trends are also getting worse for obesity (people with a body mass index or BMI of 30 or over) and severe obesity  (BMI 40 or over) as well. 

In the article on the prevalence of obesity, the researchers looked at trends from 1999-2000 to 2017-2018, using results from a very well controlled survey process undertaken by the CDC called the National Health and Nutrition Examination Survey (NHANES). This survey is repeated every two years, and most simply put is designed to give information about the health of the population in the United States. For the obesity study they had information on close to 93,000 non-pregnant persons.

Focusing here on adults, obesity increased over that time frame from 27.5% to 43.0% in men. Severe obesity increased from 3.1% to 6.9%. All groups except non-Hispanic black men were found to be affected increases in obesity, and that group of men only stopped showing an increase in obesity after 2005-6. So very close one half of the men in this country were obese in 2018.

For women, obesity increased from 33.4% to 41.9% and severe obesity went from 6.2% to 11.5% over the same time frame. That means over 1 out of every 2 women in the United States were obese or severely obese in 2018. And that doesn’t include people who were not obese but overweight. (See data graph below)

In the article using the same surveys to measure control of high blood pressure, the researchers examined the records for close to 52,000 people. Comparisons were made from 1999-2000 through 2017-2018. Their goal was to find out if the improvement in blood pressure control seen from 1999-2000 through 2009-2010 continued through 2017-2018 (the survey is done every two years). 

Not only did effective control not improve, it actually got worse. Fewer people in 2017-18 had adequate control of their blood pressure when compared to the number in 2013-2014, reversing a trend that had been getting better since 1999 (see graph). And that was based on a blood pressure of 140/90, which is now considered by some to be too high in the first place!!! 

For example, 53.8% of people with high blood pressure had their blood pressure controlled in 2013-2014. In 2017-2018, that percentage had fallen to 43.7%—roughly a 20% decline. In addition, several factors were associated with a better chance of having blood pressure controlled. These included white men compared with non-Hispanic black men; having private insurance, Medicare and government health insurance other than Medicare or Medicaid vs no insurance; having a usual health care facility vs not; having a health care visit in the past year vs not. That leaves a lot of our fellow citizens in a situation where the odds are stacked against them when it comes to control of high blood pressure. (See data graph below)

Hard to believe but true when it comes to high blood pressure, since we are not only more aware of high blood pressure than in the past, but also because inexpensive medicines work well in controlling the disease for most people. However that assumes people have access to adequate care and can afford even thee inexpensive medicines, then take the medicines as instructed. Those assumptions may be much for difficult for some and we need to recognize that as a serious problem.

An editorial which accompanied these reports and was co-authored by Gary Gibbons MD, who is the Director of the National Heart Lung and Blood Institute (NHLBI) at the National Institutes of Health (NIH) and his colleague Grffin Rodgers MD, director of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDKI) also at NIH pointed out the importance and impact of controlling blood pressure and obesity on the health of our nation, especially for young people who are obese and develop type 2 diabetes, a group for whom the consequences of obesity are even greater than for those who are older and develop the disease more frequently. In addition, the writers note that “these health indicators are moving in the wrong direction in all populations, but occur disproportionately in racial and ethnic minority groups.” 

These scientists made a passionate plea, which is so relevant to the issues we face right now:

“If the US is committed to changing the trend line of health disparities in obesity and hypertension, it is critical to acknowledge the important contributions of systemic racism and the social determinants of health in the context of the current COVID-10 crisis. It will take a collective, committee effort at every level, including policy makers, frontline community organizations, health care workers at safety-net clinics, and those conducting behavioral and biomedical scientific research, to address these potentially remediable contributors to some of the nation’s most complex health challenges. Only then will it be possible to achieve a vision of health equity in which each child born in the US is destined to live a full and healthy life regardless of their family’s zip code.”

Well said and so true.

We need to acknowledge that what we think is happening to health care in this country is not happening the way it should. Preventive care is falling behind, the result of a number of factors in including access and affordability, the declining number of primary care clinicians, and the changes in how we deliver care relying more on episodic interventions than long term engagements where the patient knows the clinician and the clinician  knows the patient among many other factors.

The list goes on and on, and is beyond the scope of this discussion at this moment. However it is so important that we pay attention, otherwise we will pay the price. We can’t blame everything on COVID. Yes, the corona virus has highlighted the shortcomings of our healthcare system, and will have impact in so many ways for so many years. The reality is that the trends described here have been developing and perhaps even accelerating for several years before we ever heard about the pandemic and the virus.

This is a topic worthy of our immediate and focused attention. We can’t bury the data, we must deal with it and acknowledge what it shows. This IS the greatest country on earth with the greatest resources to help the most people, and we can make things happen when we make a commitment to get something done. 

The implications of this research and the editorial are clear: it is critical that we pay attention to the control of these chronic illnesses that have such an impact on our health and our lives. We need to do what we need to do to get them under control.  And the sooner we do that, the better off we will all be for our efforts when it comes to the health of our nation.

From JAMA Published online August 28, 2020
From JAMA Published online September 9, 2020

2 thoughts on “Our Nation’s Health Is Heading In The Wrong Direction”

  1. Len, This is a powerful evidence-based commentary and call for action, in regards to addressing signicant population data on levels of obesity and high blood pressure. Certainly, both of these conditions are exacerbated during the COVID-19 Pandemic – and largely load disproportionately on social determinants of health. The questions I have – are how to begin to mobilize a response to address all the large scale systemic issues? How do we, as a nation take the proverbial first step of a thousand mile journey? Certainly, this is a large-scale, population-based, complex problem. And the systemic issues have been known and written about for a very long time, but with seemingly not a lot of traction. Perhaps use the conceptualization of ‘Round Tables’ with cross-institutional seeding that identify and task all participants a small piece of the whole problem – such that a combined, collaborative effort could have a chance of success. Maybe, via your blog, you might initially challenge the readership to generate some creative problem-solving ideas?! It’s a big problem – but working together on the daunting logistics might get us closer to believing that solutions are possible!

    1. Joe, thanks for your exceptional detailed comment and suggestions. You have laid down the gauntlet—let’s see if others will pick it up.

      I will say that the editorial—coming from NIH—addresses the same issues. It would appear that there must a national commitment to address these issues especially in the face of the incredible events and social dissonance we are facing today. The time is now.

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