Continuing Education Activity

Obesity is an alarmingly increasing global public health issue. Several countries worldwide have witnessed a double or triple escalation in the prevalence of obesity in the last three decades, probably due to urbanization, sedentary lifestyle, and increase consumption of high-calorie processed food. The alarming increase in childhood obesity foreshows a tremendous burden of chronic disease prevention in the future public healthcare systems worldwide. Obesity prevention is a critical factor in controlling Obesity-related Non-communicable diseases (OR-NCDs), including diabetes, cardiovascular disease, stroke, hypertension, cancer, and psychological problems. This activity reviews the public health considerations in obesity and highlights the role of the interprofessional team in developing public health strategies for the management and prevention of this condition.

Objectives:

• Review the comorbidities associated with obesity.

• Outline the psychosocial considerations in people suffering from obesity.

• Describe the individual and public health consequences of obesity.

• Identify barriers to the delayed seeking of healthcare and utilization of preventive screening programs by interprofessional team.

Introduction

Obesity is an alarmingly increasing global public health issue. Obesity is labeled as a national epidemic, and obesity affects one in three adults and one in six children in the United States of America.[1][2] Several countries worldwide have witnessed a double or triple escalation in the prevalence of obesity in the last three decades (Figure 1, Figure2), probably due to urbanization, sedentary lifestyle, and increase consumption of high-calorie processed food.[3]

The alarming increase in childhood obesity foreshows a tremendous burden of chronic disease prevention in the future public healthcare systems worldwide. Obesity prevention is a critical factor in controlling Obesity-related Non-communicable diseases (OR-NCDs), including insulin resistance/metabolic syndrome, featuring hyperinsulinemia, type 2 diabetes, hyperlipidemia, hypertension, and coronary artery disease.[4][5]

The failure of the traditional obesity control measures has stressed the importance of a new non-stigmatizing public policy approach, shifting away from the traditional focus on individual behavior change towards strategies dealing with environmental change. The other big challenge related to overweight and obesity is weight bias and discrimination. In public settings such as work environments, healthcare facilities, and educational setup, obese individuals face discrimination.

Issues of Concern

Public Health Impact of Obesity 

1. Life expectancy: Obesity, the modern lifestyle disease, not only cause serious illness but also substantially decreases the average public life expectancy. Obesity in adulthood is a strong predictor of early death. Framingham Heart Study, a prospective cohort study, revealed that adults who were obese at 40 years lost 6 to 7 years of expected life. However, in obese people who smoked, the years of life lost almost doubled.[6]
2. Quality of life: Obesity affects both the physical and psychosocial aspects of quality of life, more significant among morbidly obese individuals.  The self-perceived Health-related quality of life (HRQL) among obese individuals worsens with increasing BMI. The effect of obesity on HRQL is assessed most frequently by SF-36 (Short-Form Health Survey), comprising 36 questions covering eight domains including physical functioning, physical role limitations due to physical health problems, social functioning, bodily pain, general mental well being, emotional role limitations, energy, and general health perceptions.[7][8][9] The risk of suffering from any chronic medical condition is almost doubled in morbid obesity compared to overweight individuals.[10] Obesity causes a substantial psychological burden exacerbated by the public's marked preoccupation with thinness. Sullivan et al. reported more significant psychosocial consequences in obese women when compared to obese men.[11]
3. Prevalence of obesity-associated diseases: The individuals who are obese in their childhood tend to remain obese in adulthood and prone to high risk for Obesity-related non-communicable diseases (OR-NCD) at a younger age.[12] Obesity-related non-communicable diseases, including type 2 diabetes, coronary heart disease, stroke, cancer, asthma, and chronic obstructive pulmonary disease, have increased worldwide. These non-communicable diseases are primary targets for global disease prevention by WHO.[13] Compared with their normal-weight peers, severely obese individuals lose about eight disease-free years, and mildly obese individuals lose about four disease-free years.[14]
4. Employment: Obesity is one of the leading reasons for discrimination in the hiring process for employment, more noticed among obese females than obese males.[15] Obesity can cause reduced employment and an increase in self-reported work limitations compared to normal-weight individuals.[16]
5. Economic impact: Obesity is estimated to account for more than 20% of all annual health care expenditures in the United States.[17] The medical costs are 30% to 40% higher among obese individuals than their normal-weight peers, double the increase attributable to smoking.[18] The direct costs of obesity are attributed to the amount spent on diagnosing and treating obesity and obesity-related chronic comorbid conditions such as cardiovascular disease and type 2 diabetes. Indirect costs are attributed to the lost wages secondary to illness and premature death, elevated costs paid for disability and insurance claims, and decreased productivity at work.

Clinical Significance

The World Health Organization describes obesity as an excessive fat accumulation with body mass index (BMI) ≥25 kg/m2 labeled as overweight and BMI ≥ 30 kg/m2 labeled obesity. The relative risk of death increases with an increase in BMI. This association is non-linear, with a much higher relative risk of death for very high BMI (>30) individuals.[19] The stigma of obesity is a threat to proper healthcare resource utilization, preventing morbidity, and identifying complications early. Obese individuals have lower rates of age-appropriate preventive cancer screening.[20][21] 

Women who suffer from obesity delay seeking routine gynecological cancer screening due to many social barriers.[22] The compromise in healthcare quality in obese individuals adds to the burden of morbidity and all-cause mortality; This also imposes a significant load on the healthcare system in managing comorbidities of obese individuals. Crucial risk factors have been recognized in several studies as an effort to decrease the obesity burden, which includes the perinatal factors like maternal antenatal BMI, weight at birth and child's nutrition in the first three years of life, feeding options (breastfeeding versus formula feeding), and growth pattern in the first year.[23]

Other Issues

It is imperative to assess and address the barriers that obese patients face which delay pursuing their healthcare needs. Inadequate healthcare in these patients regarding their presenting complaints and preventive health visits leads to public health consequences in obesity. Impairment of efforts in the prevention of obesity cause health and social inequalities.[24]

Public Health Policy and Environmental Changes

Environmental changes are the best initiative in preventing the burden of obesity. A drastic public policy can bring a significant environmental change, of which some are listed below.

1. Food and Drug Administration (FDA) has made food labeling regulations that mandate calorie and nutrition labeling in all food products.
2. The FDA has officially banned trans fats in all foods sold in restaurants and grocery stores.
3. Obesity prevention priorities should focus more on children, particularly in schools encouraging healthy habits.  The local government should restrict commercial permits for fast-food restaurants nearby schools (within 0.5 miles) and encourage healthy food vendors to establish near schools.[25] 
4. School-level policies should improve physical education at school and encourage walking or biking to school.
5. Levying significant tax for unhealthy food and subsidizing healthy food are crucial strategies to prevent obesity but with few ethical limitations. Taxes on sugar-sweetened beverages such as soft drinks have been applied at most state and city levels.[26]
6. Public health policy should focus on designing activity-friendly communities by creating bike and walking paths.

Family-Based Interventions

The family-based approach is the best intervention to sustain weight loss and have weight maintenance among patients with overweight or obesity. The overweight subjects living in a family will have significant difficulties changing their lifestyle without family support. Several studies have proven that a low-fat diet with high protein and a low glycemic index effectively sustains weight maintenance and weight regain.[27][28] An easy-to-use tool in family-based dietary intervention is the traffic light diet in which food is classified as green, red, and yellow.[29] 

Weight Bias in Health Care (Figure 3)

The weight bias in the health care system can be explicit (consciously expressed) or implicit (involuntarily expressed). Implicit weight bias is not rare to see among Health care providers. Society's negative biases towards overweight or obesity often are shared and exhibited by the health care provider (HCP). The weight bias by the health care team can impair the patient's health care quality. Most HCPs believe in the energy balance theory of weight control, which encourages the thinking of obesity issues being a personal responsibility and limiting the scope of appropriate counseling.[30] The following interventions could help in reducing the weight bias in health practice. 

1. To educate the health care professionals about the complex etiology of obesity, including genetic, metabolic, and social factors.
2. To make providers aware of the fact that the weight bias could influence the quality of the care. 
3. To train the medical trainees how to communicate without implicit bias. 
4. Another strategy is to expose counter-stereotypical exemplars of people with obesity who are successful and intelligent. 
5. HCPs should address the overall health and the patient's understanding of obesity-associated comorbidities along with weight loss management. 
6. HCPs should be encouraged to use people-first language, e.g., patients with obesity instead of obese patients. Also, using terminology like high BMI instead of morbid obesity will help in motivating the patient.

Enhancing Healthcare Team Outcomes

Obesity is a national epidemic affecting every one in three adults and one in six children in the United States of America. The rising trend has been attributed to change in environmental and food practices in the face of the increasingly sedentary lifestyles of people. Tracking childhood obesity into adulthood poses a significant burden on the healthcare system for managing this and its complications. Obesity is crucial to developing non-communicable diseases (OR-NCD), which include diabetes, hypertension, coronary artery diseases, to name a few. The psychological aspect regarding the stigma of obesity leads to delay in seeking healthcare in these individuals.

While the primary care physician diagnoses obesity, it is equally important to consult with an interprofessional team of specialists, including dieticians, psychologists, behavioral counselors, and exercise specialists. When managing a child with obesity, consultation with pediatric endocrinologists, neurologists, and surgeons also has a vital role in the child's growth. Nurse practitioners are a vital part of the interprofessional group as continued and frequent motivation is needed to inculcate positive health-related changes in their daily life.

Primary care physicians can help these patients by constantly monitoring their weight and BMI and regularly scheduling annual health maintenance visits. The physician should make an effort to address any barriers that the patient perceives related to seeking healthcare. Dieticians are intrinsically involved in the management and can help create a diet plan considering the patient's personal choices and beliefs. Exercise specialists can make age-appropriate recommendations for exercise for the patient as well as family activities.

Psychological problems play a significant role in the development of maladaptive eating patterns in children and adults. The role of behavioral counselors and school-based health groups in managing children with obesity is crucial. The role of public health policymakers becomes pivotal because obesity is a preventable disease. Coordination between healthcare providers and policymakers, operating as an interprofessional team, is essential to gauge the burden of the disease, address the barriers to seeking treatment and preventive screenings. The failure of the traditional obesity control measures has stressed the importance of developing a new non-stigmatizing public policy approach by public health officials.