Are we giving the wrong advice on fitness and obesity?

What if there was a health care intervention that could save the U.S. health care system more than $300 billion? It would at least be worth hearing about, right?

Researchers estimate that obesity raises annual medical costs by more than $3,500 per obese individual. Thus, public health professionals and policy makers have sought to lower obesity rates.

The real issue is that obesity is a significant risk factor for expensive and life-threatening diseases, such as diabetes and cardiovascular disease. Heart disease is the #1 cause of death in the U.S. for both men and women, and more than half of the deaths due to heart disease are men, according to statistics issued by the CDC. Heart disease deaths vary by geography though. As this map shows, from 2008-2010, death rates due to heart disease were highest in the South and lowest in the West.

Source: CDC

There are many common risk factors for heart disease. For example, high blood pressure, high cholesterol, and smoking are key risk factors for heart disease. About half of Americans (47%) have at least one of these three risk factors, the CDC says. Several other medical conditions and lifestyle choices can also put people at a higher risk for heart disease, including:

• Diabetes
• Overweight and obesity
• Poor diet
• Physical inactivity
• Excessive alcohol use

This means that most public health education is generalized to say things like “You should improve your lifestyle,” in order to decrease your risk for the #1 killer – heart disease.

However, new research says the advice should be much more specific.

“I think one of the reasons for failure of public health initiatives in modifying lifestyle behavior is giving a blanket message of improving lifestyle, which includes healthy eating, exercising, not smoking, and a bunch of other factors,” Ambarish Pandey, University of Texas Southwestern Medical Center, Dallas told Medscape.

In a study published in JACC: Heart Failure in April 2017, Pandey and colleagues evaluated nearly 20,000 people for more than six years; as expected, they found that people who were overweight or obese were more likely to have the traditional cardiovascular disease risk factors noted above. These individuals were also likely to have lower cardiorespiratory fitness (CRF).

The researchers also found that CRF accounted for 47% of the risk of heart-failure hospitalization associated with increased BMI. “These findings highlight the importance of CRF in mediating BMI-associated heart failure risk,” they conclude.

“I think our study shows that we could target low fitness and exercise more aggressively and more tactically than BMI or body weight and encourage people to exercise more,” Pandey said. “Obviously a higher BMI is bad and lower BMI is better, at least at the normal range, but I think focusing more on fitness and exercise and focusing more on the level of physical activity may be the greater goal in the near future to better improve the risk of cardiovascular diseases.”

Of course, there are many problems with reducing cardiovascular risk by advising people to exercise more, and maybe even helping them do so, not the least of which is that it is not a medical intervention. In other words, no physician or other health care provider gets paid to recommend it.

Who should pay to help people exercise more? Should employers pay for your gym membership or P90X® workout videos? When a person moves from a low level of fitness to a moderate level of fitness – which is the most beneficial in terms of reducing cardiovascular risk – who should get credit in a world moving to value-based payment?

Changing what we pay for in health care will in turn change what interventions are delivered.

That is much more easily said than done, however, if interventions that work are not delivered by the medical professionals who get paid by health insurers or other third-party payers, such as federal and state governments.

Another solution would be to pay physicians to conduct these interventions. Why shouldn’t a medical professional get paid to do what works?