Introduction
Overweight and Obesity
In the past 3 decades, obesity has been considered as one of the major health issues associated with high morbidity and mortality rates. Many developed and industrialized nations have observed similar trends; however, the rate of obesity in the United States is considered to be the highest in the world (Choquet, H., & Meyre, D. 2011)
Obesity is known to grow in an exponential rate within the United States. Based on a recent survey, 1 out of every 3 individuals in America are either overweight or obese. The data also revealed that the US was the only country in the world to have the highest rate of obesity in the 21st century. An estimate of 120,000 preventable deaths have occurred arising due to obesity in the United States. The average cost incurred by an overweight or obese individual is around $1,500 with respect to medical expenses on an annual basis. An annual expenditure of up to $145 billion is spent in the US associated with medical expenses linked with obesity.
Based on the survey of obesity in Organisation for Economic Co-operation and Development member countries, the US stood first followed by Mexico.
The rate of obesity has increased consistently since 1962 (wherein obesity accounted for 13%) in the US. The rate of obesity in the US for adults above 20 years living within the poverty level was calculated as follows: The obesity rate for adults was 19% in 1997, 25% in 2004, 27% in 2007, and 33$ in 2008. The rate of obesity had also increased among children with a prevalence of 17% in the US.As per a recent report by the Centres for Disease Control and Prevention (CDC) in 2010, the rate of obesity was substantially high with 36% of adults and 17% of children diagnosed with obesity. A recent report published in 2013 by the Organisation for Economic Co-operation and Development (OECD) revealed that 27% of adults in the US were obese.
It is estimated that nearly 3/4th of the population in the US, including children are likely to be overweight or obese by 2020. In the 2014 report released by the CDC, nearly 3/4th (approximately 79 million or 35%) of people in the US are obese with children accounting for over 17% of obesity. Adolescents in the age group of 2 to 19 years have also been observed to have high rate of obesity. In the US, nearly 100,000 people die due to obesity associated preventable deaths. Nearly 400,000 cases of obesity are known to be linked with increased healthcare expenditure. Approximately $117 billion is spent on direct expenses associated with obesity (Prevention, diagnosis, and treatment). The costs also include indirect factors such as premature death, absenteeism, and loss of future earnings. The overall expenses increases by over 8% if associated with smoking and other lifestyle factors in the US. Thus, obesity has become a prominent health problem in the US healthcare system.
Current practice associated to obesity
Since the US is considered as the breeding ground for obesity, there have been number of strategies to prevent and control its incidence and prevalence. The basic and first line strategy includes patient education and communication on obesity. Primary healthcare education takes place in schools and colleges in order to prevent and control early stage obesity. The dietary and physical activities of children and adolescents are monitored on a regular basis in order to prevent long-term health issues linked with obesity. Many policies and regulations have been implemented in schools to control the risk of overweight and obesity among youth. In adults with obesity, lifestyle modifications coupled with dietary recommendations and medications (if required) are the currently practiced by healthcare professionals in the US. Many guidelines such as the joint recommendation by the American College of Cardiology and American Heart Association have been published for the treatment and management of obesity in the US.
Obesity/Overweight and impact on patient’s cultural background
Obesity plays a distinctive role in the healthcare system. The patient affected with obesity and associated health issues is known to suffer from various factors linked with lifestyle and other socioeconomic conditions. Based on current research, patients with obesity are known to be affected on 5 factors that are as follows:
Culture: The patient’s cultural background is an independent factor that is linked with obesity. For example, people in metro or urban areas in the US are more likely to develop obesity compared to their counterparts based in rural or semi-urban settings. The cultural factors such as food, lifestyle, and occupation are linked with obesity.
Race/Ethnicity: African-Americans are predominantly known to suffer from obesity due to lifestyle and genetic factors compared to White Americans. Sedentary lifestyle coupled with poor dietary choices are known to increase the risk of obesity among youth and adolescents based in the USA. Individuals with obesity are also at high risk of developing chronic conditions such as diabetes, cardiovascular disease, and/or stroke.
Occupation: Nearly 70% of patients with obesity are based in urban and modernized settings associated with a sedentary lifestyle and poor dietary choices. Individuals in the corporate sector are prone to suffer from obesity.
Household size: The household size may also have impacted that risk of obesity since a large family size with a poor economic background would opt for unhealthy and poor dietary choices. A nuclear family with sufficient funds would live a healthy lifestyle.
Income: Income plays a critical role in an individual’s lifestyle. Income defines the socioeconomic condition of an individual. However, as per a recent survey, individuals from high income corporate sectors were known to have high rates of obesity and other chronic conditions such as diabetes and heart disease.
Overweight/Obesity
As per the latest report by the CDC, more than 65% of the population is overweight in the USA with over 35% of adults confirmed to being clinically obese. 1 in every 20 individuals in the USA are known to suffer from extreme obesity. The CDC report released in 2014 states that Non-Hispanic blacks account for over 47% of obese cases followed by Hispanic accounting to 42% obesity cases. Non-Hispanic Whites account for 32% while Hispanic Asians account for 10% of obesity cases.
Intervention: Patient education and awareness form a critical role in the prevention and control of obesity. The main objective of patient education is to promote the benefits of physical activity and healthy diet among youth and adolescents. Dietary modifications among adults with sedentary lifestyle and poor dietary choices is highly recommended.
Comparison: The intervention would be compared with communities/individuals who do not receive primary education and awareness. Poor socioeconomic standards are also linked with high risk of obesity.
Outcome: The overall outcome of the intervention would be to reduce the morbidity and mortality associated with obesity. It would also be aimed to reduce the incidence and prevalence of obesity in the US.
PICO Table
Search Strategy
The search strategy included databases such as PUBMED, CINHAL, Google Scholar, EMBASE, and EMEDLINE. All articles published 2011 and later were selected as the primary resource for research and analysis. Papers in English were only selected with high quality evidence. Papers such as single case study, case reports, and case reviews were excluded from the study. High quality evidence such as meta-analysis, randomized control studies, systematic reviews, cohort studies, and review articles were referred for the study.
Key words: Obesity, overweight, USA, adults, adolescents, mortality, morbidity, prevalence, incidence, and comorbid disease were select keywords that were used for the primary and secondary research of papers
Types of articles: Most of the articles were meta-analysis, systematic reviews, randomized controlled trials, cohort studies, review articles, guidelines, and consensus statements. A few unpublished articles were also included in the study to avoid bias. Governmental websites and educational/institutional websites were also included in the study.
Research-based evidence
Obesity and discrimination - a systematic review and meta-analysis of observational studies: Obesity has been linked with several life threatening diseases. There is limited evidence on the social discrimination of individuals with obesity in the US. Researchers from Germany evaluated the gaps between discrimination and people with obesity. They reviewed 9 critical studies and linked with social discrimination factors observed among individuals with obesity. It was observed that people with a high body mass index (BMI) had higher rate of discrimination compared to individuals with normal body weight. Most of the discriminations were based on social interaction, employment, and other activities that lead to a depression and anxiety among individuals with obesity (Spahlholz J, et al. 2016).
Obesity and iron deficiency: a quantitative meta-analysis: Based on a few research studies, obesity individuals were found to suffer from Hypoferraemia (iron deficiency). Researchers from China confirmed that individuals with extreme obesity had a high risk of developing Hypoferraemia that could also lead to several health complications. The rate of obesity with iron deficiency in the US is low but longitudinal studies need to be conducted to confirm the link between both chronic lifestyle diseases (Zhao L, et al. 2015).
Non-research based evidence
Two papers that were not based on research but conducted through a survey concluded that there were many misconceptions on the dietary intake and lifestyle factors. Based on these unpublished articles, there were 3 factors that were addressed linked with high rate of obesity in Americans. The first factor is the large portion of food consumed within the 3 meals they have in a single day. The mid-meal snacks also high in calories and low in nutrition. The second factor is the confusion between diet and nutrition. The third factor is the sedentary lifestyle and low physical activity for all age groups (Public Health, 2016).
Evidence Matrix (Attached table)
Recommended Practice change based on PICO
Obesity is a lifestyle health issue that can be prevented and controlled with effective treatment and management strategies. Based on current research, Americans are more likely to die of heart disease and stroke owing to obesity (Spahlholz J, et al. 2015).
Prevention of overweight and obesity in adults: The first line to the management of obesity among the youth and adults is prevention. Awareness and education on the risks of obesity coupled with a healthy lifestyle is known to prevent obesity. Patient education campaigns, school and college events, social group meetings are some means to educate and prevent obesity among youth and adults (Sackner-Bernstein, J., Kanter, D., & Kaul, S. 2015).
Health benefits of weight loss: Researchers and healthcare professionals recommend weight loss as an ideal intervention since it is associated with many health benefits. Based on current evidence, there are 4 key benefits of weight loss that include low risk of hypertension and heart disease, improved quality of life, low body mass index and waist circumference, and low levels of depression and anxiety. Weight loss is known to improve the confidence of an individual and also helps in controlling and preventing serious health issues. As per a recent survey, people who followed weight loss management programs are known to live a quality life (Levine, J. A. 2011 and Li, Q., Blume, SW., Huang, JC. Hammer, M, & Graf, TR. 2015).
Dietary Interventions: A healthy diet is recommended for people with obesity. A combination of fresh fruits and vegetables is recommended for individuals with high BMI. A well balanced diet should comprise of right amount of proteins, carbohydrates, and fats. . Dieticians recommend a low fat and protein. It is recommended that individuals avoid foods such as donuts, pastries, cream rolls, pizzas etc. Vegetables such as broccoli, lettuce, spinach, carrots etc while Fruits such as apple, apricot, pear, watermelon, and kiwi are recommended.
Physical activity: Based on current evidence, physical activity is highly recommended for overweight and high BMI individuals. Sedentary lifestyle is a major cause of obesity and individuals are recommended light to moderate exercise. Physical activity such as walking (For 60 mins/day), jogging (For 30 mins/day), cycling (For 30mins/day), or swimming (20 mins/day) is highly recommended (Hruby, A., & Hu, F. B. 2015).
Pharmacological Treatment: In the case of extreme obesity, healthcare professionals recommend the use of pharmacological treatment. Some of the key factors while considering such treatment include BMI of 30 and above and/or coupled with health complications such as hypertension or diabetes. Most common drugs include orlistat, lorcaserin, phentermine and topiramate, buproprion and naltrexone, & liraglutide (The GBD 2013 Obesity Collaboration)
Bariatric Surgery in adults: In extreme cases, wherein individual’s BMI is 40 and above and at high risk of hypertension, CVD, and stroke. Weight-loss surgery also known as bariatric surgery is highly recommended. Some of the common surgeries include Gastric bypass, Laparoscopic adjustable gastric banding, Biliopancreatic diversion with duodenal switch, and Gastric sleeve (Herrera, B. M., Keildson, S., & Lindgren, C. M. 2011).
Referral and service provision in adults: In individuals with health complications such as diabetes, hypertension, heart disease etc. healthcare professionals often refer to special services such as physiotherapist, cardiologist, and endocrinologist.
Implementation
The treatment and management of overweight and obese individuals is highly complex and involves multi-special and interdisciplinary team of experts. The first choice of healthcare professional would involve a physician who would refer the patient to a dietician, physiotherapist, and a consultant (cardiologist and/or endocrinologist). These three healthcare professionals would be considered as the primary stakeholders for the implementation plan. Secondary stakeholders would involve family members, caregivers, and nurse professionals.
Key stakeholders: The physician would monitor the health (especially weight) of the patient at regular intervals. Based on the feedback by the dietician and consultants, the physician may also recommend the patient to other healthcare professionals. The stakeholder’s primary objective is to reduce the weight of the patient by recommended and evidence-based treatment and management strategies. Some of the common strategies would include weight loss management program, diet and physical interventions, lifestyle modifications, and nurse or caregiver-based management programs (Gallagher, E. J., & LeRoith, D. 2015).
Barriers in implementation: Based on current evidence, most healthcare professionals would come across various barriers in managing obese patients. Some of the key barriers include culture, education, socioeconomic status, race/ethnicity, lifestyle, and attitude. Most African-Americans are likely to have high-fat and oil-rich foods that is part of their culture. They also have misconceptions on diet and nutrition which causes significant issues among healthcare professionals. The lack of education may also impact the level of understanding on overweight, obesity, and other complex health issues. Low income and socially unstable or insecure individuals are more likely to resist the modern-day management strategies on obesity. Lastly, the race, lifestyle, and attitude of an individual towards the disease has a direct impact on obesity management (Chaput, JP, et al. 2014).
Strategies to overcome barriers: Healthcare professionals and researchers are keen to develop robust and patient friendly management programs/strategies. Some of the key strategies that should be included are as follows:
Patient Education Campaign (Community centre): A community-level awareness and education program enables individuals of all age groups, race, and culture to participate. It would help in understanding various forms of health issues linked with obesity. Individuals would also interact with fellow participants and indulge in improved lifestyle and dietary interventions (Chaput, JP, et al. 2014).
Subsidized and access to healthcare services: In low income groups, access to healthcare is a critical barrier. Collaboration with an NGO or a government-based entity to provide free or low-cost healthcare services would help individuals with obesity and comorbid conditions access healthcare services.
Online or mobile-based social awareness: In the world of technology, applications such as Watsap, Viber, and Facebook can have a major impact on social awareness on obesity on a large scale. In the pre-text of large scale communication, social media platforms serve a better alternative for healthcare education (Fildes, A., et al. 2015)
Indicator to measure outcome: Based on the overall treatment and management strategies, a short survey form can be developed and circulated in order to assess the effect on weight and other health parameters. The survey would include parameters such as weight, diet, lifestyle, and other healthcare parameters. A cumulative analysis of the survey can help in determining the outcome of theobesity treatment intervention. Weight loss and lifestyle would considered as key outcome measures (Zhao L, et al. 2015).
References
Choquet, H., & Meyre, D. (2011). Genetics of Obesity: What have we Learned? Current Genomics, 12(3), 169–179.
Chaput, J.-P., Ferraro, Z. M., Prud’homme, D., & Sharma, A. M. (2014). Widespread misconceptions about obesity. Canadian Family Physician, 60(11), 973–975.
Fildes, A., Charlton, J., Rudisill, C., Littlejohns, P., Prevost, A. T., & Gulliford, M. C. (2015). Probability of an Obese Person Attaining Normal Body Weight: Cohort Study Using Electronic Health Records. American Journal of Public Health, 105(9), e54–e59.
Gallagher, E. J., & LeRoith, D. (2015). Obesity and Diabetes: The Increased Risk of Cancer and Cancer-Related Mortality. Physiological Reviews, 95(3), 727–748.
Herrera, B. M., Keildson, S., & Lindgren, C. M. (2011). Genetics and epigenetics of obesity. Maturitas, 69(1), 41–49.
Hruby, A., & Hu, F. B. (2015). The Epidemiology of Obesity: A Big Picture. PharmacoEconomics, 33(7), 673–689.
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Levine, J. A. (2011). Poverty and Obesity in the U.S. Diabetes, 60(11), 2667–2668.
Li, Q., Blume, S. W., Huang, J. C., Hammer, M., & Graf, T. R. (2015). The Economic Burden of Obesity by Glycemic Stage in the United States. Pharmacoeconomics, 33(7), 735–748.
Sackner-Bernstein, J., Kanter, D., & Kaul, S. (2015). Dietary Intervention for Overweight and Obese Adults: Comparison of Low-Carbohydrate and Low-Fat Diets. A Meta-Analysis. PLoS ONE, 10(10), e0139817.
Spahlholz J, et al. Obesity and discrimination - a systematic review and meta-analysis of observational studies. Obes Rev. 2016 Jan;17(1):43-55.
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