In Louisiana, Efforts to Address Obesity Must Consider the Whole Person, Work Outside the Clinic, and Respect Culture

The American Journal of Accountable Care. 2023;11(4):67-70. https://doi.org/10.37765/ajac.2023.89479

The term food insecurity can call to mind someone who is malnourished or starved, but increasingly, experts are beginning to recognize that the reduced quality and variety of diet seen with food insecurity often go hand in hand with obesity, a common condition that is a major driver of poor health outcomes on the individual and population levels. The factors contributing to both food insecurity and obesity are numerous and complex, but the resources available to address them are growing—from value-based payment models to user-friendly apps to pharmacological therapies for weight management.

These challenges and opportunities were discussed at an Institute for Value-Based Medicine^® (IVBM) population health event held in New Orleans, Louisiana, on November 7, 2023. The event, held by The American Journal of Managed Care^® in partnership with Ochsner Health, featured faculty from the health system and its university, employer, and community partners, with a focus on improving wellness and food security in Louisiana.

Event cochair Eboni Price-Haywood, MD, MPH, MMM, medical director of the Ochsner-Xavier Institute for Health Equity and Research and a professor at Ochsner Clinical School at the University of Queensland in Australia, set the stage for the discussion by providing “the state of the state.” Louisiana’s consistent place near the bottom of state health rankings led to the creation of the Healthy State initiative, which is led by Ochsner and leverages resources across more than 40 partner organizations in the community.

With a goal of “collective impact through collective action,” Price-Haywood explained, the organizations have a shared agenda focusing on 6 priority areas, which include ending hunger and ending obesity as well as broadband connectivity, smoking cessation, reducing cancer and chronic conditions, and strengthening the workforce and education. She said the advisory board believes these areas will have the most impact on improving the state’s ranking of health by measures such as premature death, food security, and physical activity.

The prevalence of food insecurity is higher in the South, and Louisiana is no exception, with an estimated 683,000 residents living with food insecurity, Price-Haywood said, citing data from the US Department of Agriculture and Feeding America. In particular, New Orleans has the highest metro-level rate of food insecurity among adults 60 years or older, at 13.8%, and 4 in 10 college students in the state experience food insecurity. The factors are multilevel and often linked to social determinants of health (SDOH), ranging from limited grocery budgets forcing shoppers to choose less nutritious options to transportation barriers and food deserts that confine individuals to shopping at convenience stores that offer mainly processed foods. Food insecurity is also linked with obesity,¹ which is more prevalent in Louisiana than the national average, and Price-Haywood mentioned that the chronic conditions linked to obesity span the body from head to toe, from dementia to diabetes.

Resources such as the Supplemental Nutrition Assistance Program (SNAP) and Special Supplemental Nutrition Program for Women, Infants, and Children are helpful for addressing food insecurity, but there are challenges to enrollment, and only approximately half of Louisianans with food insecurity meet the eligibility criteria for SNAP. Because of these unmet needs and the serious medical and financial consequences of food insecurity and obesity,² “the importance is, with each industry, to reflect on whoever it is that you’re responsible for,” Price-Haywood said. “How do you assess food insecurity in your population, and what can you do?... Regardless of the industry that you’re talking about, we have to be connected to the community.”

Next up to discuss strategies to address the complex relationship between food insecurity and obesity was a panel led by cochair Peter T. Katzmarzyk, PhD, the Marie Edana Corcoran Endowed Chair in Pediatric Obesity and Diabetes, a professor of physical activity and obesity epidemiology, and the associate executive director of population and public health sciences at Pennington Biomedical Research Center at Louisiana State University in New Orleans. He first asked Denise Holston, PhD, MSc, RDN, LDN, an associate professor at Louisiana State University AgCenter in Baton Rouge, to follow up on Price-Haywood’s thoughts on the importance of community partnership.

Holston said that her experience implementing research-based interventions across the parishes of Louisiana has taught her that there is no one-size-fits-all solution to food insecurity. Beliefs and attitudes vary, so each community needs to be engaged through outreach and open forums to cocreate solutions that are acceptable and sustainable.

“If you drop an intervention down into a parish and expect that it’s going to be disseminated and it’s going to be taken up, it’s not going to happen,” Holston warned. “As soon as your hands go off of it, that intervention will stop, essentially.”

Panelist Katie Queen, MD, a pediatrician at Our Lady of the Angels Health in Baton Rouge and Bogalusa, Louisiana, discussed some of the exciting innovations taking place in the childhood obesity space. Guidelines are becoming more proactive in suggesting counseling, referral to community programs, and use of medications and bariatric surgery when warranted for older children.

Although there has been some pushback in the media around the idea of giving the novel weight loss medications to youth, Queen explained that these medications actually fix the metabolic signaling imbalance in how the brain, gut, and hormones interact, so they are acting on a pathophysiological level, not just cosmetic. Queen and her colleagues have seen impressive results not just in reducing body mass index but also in alleviating cardiovascular risk factors—even in the example of her 12-year-old patient who was able to stop using a continuous positive airway pressure machine for sleep apnea after losing weight. Once the media and the public begin to realize these benefits, she predicts more widespread acceptance.

“Twenty years ago when Lipitor [atorvastatin] came out, I heard there was a big backlash as well,” Queen reminded the audience, “so I think it’s just going to take time for people to understand.”

In response to an audience question about the safe use of weight loss medications in youth, Queen emphasized that clinicians aren’t just prescribing the drugs as a 1-step solution; rather, comprehensive obesity care also offers mental health support and resources to address SDOH as well as care for any comorbid conditions. The interest from attendees embodied the excitement surrounding these drugs in the larger medical community, especially timely because another option, tirzepatide (Zepbound), would be approved by the FDA for weight management just the day after the event.³

Another important point often not understood by the public is that food insecurity doesn’t mean just malnutrition and starvation because it actually has a strong bidirectional relationship with obesity, according to panelist Candice Myers, PhD, MS, an assistant professor of research and director of the Social Determinants and Health Disparities Laboratory at Pennington Biomedical Research Center at Louisiana State University in Baton Rouge. She explained that food insecurity can encompass the inability to prepare nutritious foods, skipping meals or eating at strange times, and perturbed eating patterns. These patterns can have not only dietary consequences but also psychological and physiological effects as a source of stress in a household or family.

“We are better trying to understand why food insecurity not only impacts poor diet but [also the] other mechanisms or pathways by which food insecurity can lead to greater body weight, and some of the things we’re looking at are stress and psychological functioning,” Myers said.

The drivers of food insecurity and obesity are complex and difficult to address, the panelists agreed, and healthy lifestyle changes are tough for individuals to prioritize amid all the other pressures of their daily lives. The panelists were excited to hear the employee wellness approach described by panelist Franck LaBiche, JD, human resources director at Laitram, LLC, a manufacturing company in Louisiana. This approach incorporates nurse practitioners, behavioral health counselors, a dietitian, a physical therapist, a dentist, and other care providers into 2 onsite clinics for employees, all with the goal of reducing barriers to accessing care.

In particular, LaBiche described how an initiative targeting obesity has provided employees with subsidized healthy meals, remote monitoring equipment, and health coaching, leading to an average of 42 lb lost per person, with decreases in hemoglobin A_1c and triglyceride levels. Beyond these biometrics, “the feedback we get from these individuals on the life change they’ve made has been phenomenal,” LaBiche said. “They’ve all struggled with weight loss over the years, and now they think they’ve found a sustainable program that works for them.”

In response to an audience question about how to make these interventions scalable across a population, Katzmarzyk said that it will start with medical education and changes to the clinical workflow, but scalability will also require payers to cooperate by rewarding practitioners for these efforts, similar to the reimbursement models increasingly seen in value-based care programs.

Another key to scaling up efforts to improve wellness is ensuring that any changes are acceptable within the local culture, and the next speaker, Molly Kimball, RD, CSSD, founder of Ochsner’s Eat Fit initiative and director of nutrition at Ochsner Fitness Center, explained how this approach works in Louisiana, a state renowned for its zesty and delicious cuisine. Eat Fit works with restaurateurs, chefs, food truck owners, and other establishments to collaborate on dishes that meet nutritional criteria without sacrificing taste. These dishes are awarded the Eat Fit seal of approval on menus, and the Eat Fit mobile app helps diners find participating locations. In addition, there are also Eat Fit cookbooks, weekly e-newsletters, and social media channels that provide recipes, grocery guides, and motivation to make more healthful choices.

Kimball emphasized that the initiative focuses on education, not judging chefs or consumers, and this approach accounts for its success, with internal data showing that 89.6% of customers reported that having the Eat Fit menu options helped them make healthier food choices. Also, 70 of 71 participating restaurant owners or managers said they thought that Eat Fit was easy to implement.

“Eat Fit is a program that can be replicated, it has high validity, and it can be implemented with fidelity,” Kimball said. Those principles were put to the test by IVBM attendees, who had the chance to sample the Eat Fit–approved mango chicken salad created by Ryan Conn, executive chef at Ochsner Fitness Center.

After time to enjoy this and other healthy food options during the reception, the evening continued with a discussion between Beau Raymond, MD, chief medical officer of Ochsner Health Network, and Julie Henry, MBA, chief operating officer of Ochsner Digital Medicine. Raymond explained how value-based care, with reimbursement based on quality, has created opportunities for Ochsner Health Network to address SDOH and encourage optimal health by partnering with physicians and employers on data sharing and population health initiatives.

He noted that interventions that work equally across a whole population can help achieve progress on health goals but that these interventions won’t close the gaps representing health inequities, like those between Black and White patients for diabetes control or between men and women for statin prescribing. Closing those gaps will require a tailored approach in each region, armed with data and information on the opportunities for improvement.

“This isn’t something where you create one program that works across the entire state,” Raymond said. “We really need a regional look as to how we’re going to do things, so that’s why we’re taking this information and sharing it with others.”

One example of a program that has been adapted and expanded to work not only in Louisiana but also for patients in all 50 states is the Ochsner Digital Medicine program, which pairs digital technologies with relationship-based care from a dedicated health coach, Henry explained. This coach meets the patient where they are to advise them on grocery shopping, medication affordability, and lifestyle adjustments, and patients with all levels of technological literacy and device access are supported through the process of using the digital tools.

“One of the great opportunities of having value-based agreements and arrangements as an organization is it allows us to make investments with digital programs and innovative tools with those populations,” Henry said. Results show improvements in clinical benchmarks, care utilization, and costs, and just as important is the patient satisfaction feedback, with Net Promoter Scores of 87.

Henry noted that these results are seen across varying patient characteristics and that the highest Net Promoter Score is seen in the Medicaid population. “That score of 91, the highest of any of our participants, really speaks to the importance of having equitable access to care for those who have historically felt marginalized or underrepresented,” Henry said, drawing applause.

In response to an audience question about how to get these interventions to the population without internet or a smartphone, attendee Kristy Nichols, MS, system vice president of government relations and public policy at Ochsner Health, emphasized that broadband connectivity is a priority for the Healthy State initiative. Connect Louisiana, a state resource that partners with Healthy State, is being aggressive about maximizing the federal funding opportunities to eliminate disparities in internet access, but there is still room for improvement in internet literacy and affordability.

Other areas for improvement were highlighted during a panel discussion on cross-sector efforts to scale up food access, nutrition, and wellness education, led by Christy Reeves, MBA, MLIS, vice president of community engagement and impact at Ochsner Health. First was Pavan Chava, DO, an endocrinologist with Ochsner Health, who discussed the near impossibility of practitioners managing in a brief clinic visit to address all the barriers that prevent patients from achieving their health goals. Clinicians need to leverage electronic health record tools to capture information and then link patients to resources and interventions that are culturally appropriate and feasible.

“The American health care system is designed around sickness historically, not necessarily health, and that’s actually changing rapidly,” Chava said. “Health care systems have their strengths, but all these [community partner] organizations have a lot of strengths and they’ve been working in this space for a very long time. So it’s everyone working together and rowing in the same direction to help get people what they need.”

One of those community partners was represented by Pat Van Burkleo, executive director of Feeding Louisiana. He discussed the expanding role of food banks as they work to provide direct services to the community through innovations like mobile pantries and childhood nutrition programs. He also mentioned the larger structural conditions needed to enable wellness on a population scale, saying, “We can talk about why people are hungry, but we need a livable wage and we need education. Hunger is such a small part of the problem because it’s layered on layers and layers.”

Susannah Craig, PhD, the Louisiana Board of Regents’ deputy commissioner for strategic planning and student success, discussed the hunger-free campus initiatives aiming to eliminate hunger in higher education, noting that food insecurity is high in Louisiana’s 2-year institutions and even higher for students of color. The board is working to create a network of on-campus food pantries that can share best practices with one another and, in conjunction with the national Swipe Out Hunger initiative, has begun to implement swipe sharing for meal cards on campus. “It’s so much bigger than just the food pantry; that’s just the beginning for us,” she said. She and Van Burkleo agreed that the requirement for SNAP recipients to work 20 hours per week is a huge impediment to students receiving this assistance, signaling the need for policy change.

The importance of a connected network of collaborators with a common goal was echoed by John Spain, senior advisor to the Baton Rouge Area Foundation. In the Baton Rouge Health District, hospitals that are otherwise competitors are coming together on the larger vision to work on access to care, transportation, food shortages, and other factors that affect life expectancy. He noted that the ability to respond quickly and tear down the silos across sectors is the foundation’s biggest asset.

“These conversations always start about money, and I would say it’s never about money. It’s always about leadership, and it’s always about the right idea,” Spain said. “And the money will always follow the right idea.”

In response to a question from the audience about the efficacy of produce prescriptions, Queen mentioned that her organization has started a food prescription program in Bogalusa, Louisiana, that provides more than 100 families with a Walmart debit card holding $60 to spend on fresh fruits and vegetables each month paired with nutrition education at the YMCA. It will next be scaled up to Lafayette and then to the whole state of Louisiana with Medicaid as a partner.

Price-Haywood returned to the podium to wrap up the event, noting the variety of perspectives that each have the potential to effect change and lead to a healthier state.

“As we’ve learned today, the stakes are high in Louisiana, and we have excellent initiatives and partners working together to create innovative and very thoughtful solutions to the problems that we face,” Price-Haywood concluded. “Our motto is collective action for collective impact, and we can’t do this alone—we have to do things that support each other in this journey.”

Author Information: Ms Mattina is an employee of MJH Life Sciences^®, parent company of the publisher of The American Journal of Accountable Care.

REFERENCES

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2. Hruby A, Hu FB. The epidemiology of obesity: a big picture. Pharmacoeconomics. 2015;33(7):673-689. doi:10.1007/s40273-014-0243-x

3. Joszt L. FDA approves diabetes drug tirzepatide for chronic weight management. AJMC. November 8, 2023. Accessed November 14, 2023. https://www.ajmc.com/link/4954