DIRECTIONS & DISCLOSURES
1. Please read the below article carefully.
2. Complete the post-test, evaluation form and the registration form.
The post-test will be reviewed. If a score of 70 percent or better is achieved, a certificate will be emailed to you. If a score of 70 percent is not achieved, a letter of notification of the final score and instructions on how to a second post-test will be emailed to you. We recommend that this independent study be reviewed prior to taking the second post-test. If a score of 70 percent is achieved on the second post-test, a certificate will be issued.
If you have any questions, please contact the Ohio Nurses Association’s CE department at sswearingen@ohnurses.org.
There is no conflict of interest among anyone with the ability to control content of this activity.
Criteria for successful completion: Completion of post-test with a score of 70% or higher.
Expiration Date: 9/30/2020
1 contact hour awarded with successful completion.
The Ohio Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. (OBN-001-91)
STUDY
Obesity continues to be a growing global health problem. Unfortunately, the United States ranked 12th for adult prevalence rate of obesity in 2016 (Central Intelligence Agency [CIA], 2016). Per the World Health Organization (WHO) (2018), “worldwide obesity has nearly tripled since 1975.”(World Health Organization [WHO], 2018). Obesity is a costly and deadly epidemic, and it is preventable.
What Is Obesity?
Technically, obesity is “an excess of adipose tissue” (Obesity Society, 2016). The Centers for Disease Control and Prevention (CDC) differentiate being overweight and being obese with Body Mass Index (BMI) (Centers for Disease Control and Prevention [CDC], 2016). Body Mass Index is a calculation based on your height and weight.
The following chart depicts the differences, for adults:
- “If your BMI is less than 18.5, it falls within the underweight range.
- If your BMI is 18.5 to <25, it falls within the normal.
- If your BMI is 25.0 to <30, it falls within the overweight
- If your BMI is 30.0 or higher, it falls within the obese
Obesity is frequently subdivided into categories:
- Class 1: BMI of 30 to < 35
- Class 2: BMI of 35 to < 40
- Class 3: BMI of 40 or higher. Class 3 obesity is sometimes categorized as “extreme” or “severe” obesity.”
(CDC, 2016). The World Health Organization cites the same BMI standards for determining adult overweight and obesity (WHO, 2018).
Determining obesity in children works a little differently. The CDC describes it as “BMI-for-age” (Centers for Disease Control and Prevention [CDC], 2016).
Overweight, Children: BMI at or above the 85th percentile and below the 95% percentile for children and teens of the same age and sex
Obese, Children: BMI at or above the 95% percentile for children and teens of the same age and sex (CDC, 2016).
The problem with obesity is that its danger doesn’t stop with weight. There is a plethora of evidence in the literature supporting the correlation between obesity and other chronic diseases, such as diabetes, hypertension, heart disease and cancer (Aune et al., 2016). Additionally, obesity has been directly associated with an increased “all-cause mortality” rate (Aune et al., 2016).
Prevalence in Ohio
Sources estimate that in 2016, 31.5%-32.6% of Ohioans were obese (Centers for Disease Control and Prevention [CDC], 2016)(Robert Wood Johnson Foundation, 2016). The CDC estimates that 13% of adolescents in Ohio had obesity (CDC, 2016).
The state of Ohio has several programs in place to assist its residents in getting and staying healthy. These programs including training for parents, families, and healthcare providers (CDC, 2016). The Ohio Department of Health partnered with other groups to offer specialized training and education to child care centers that centered around healthy nutrition and physical activity recommendations for the children they serve (Oppenheim, 2016). Because children who are overweight and/or obese are more likely to remain this way as adults, it is imperative that families and healthcare providers alike do everything possible to improve the nutrition and exercise habits of children.
Causes of Obesity
Obesity is a disorder with multi-factorial causation. There is no one single factor that will definitively cause obesity. Causative factors include poor diet and nutrition with insufficient exercise and physical activity (Centers for Disease Control and Prevention [CDC], 2018). Genetics may play a role for some, making it harder to lose excess weight and easier to gain. However, genetics are not a guarantee that one will develop obesity. Behavior modification, healthy eating and regular exercise can help combat poor genes.
Some medical conditions and medications can also contribute to weight gain (CDC, 2018).
There have been some correlations discovered between obesity rates and socioeconomic status (CDC, 2018)(CDC, 2016). Statistics show that Hispanics and non-Hispanic blacks have higher incidences of obesity than other races (CDC, 2018). Connections between income level and obesity rates have been made, particularly with obese women (CDC, 2018).
Community plays a role as well. To eat healthy, one must have access to affordable, healthy food. To be regularly active, one must have a safe place to exercise or allow their children to be active in. Schools need to be equipped with healthy options for students as well as comprehensive physical education.
Health Implications of Obesity
There are numerous health implications of obesity. Carrying excess weight can affect nearly every system in the body, including mental health.
These dangerous co-morbidities are not just affecting adults, either. One study’s calculations estimate that by 2025, as many as 91 million children and adolescents (ages 5-17) globally will be obese (Lobstein & Jackson-Leach, 2016). Additionally, the study researched the estimated prevalence of the following obesity-related co-morbidities in this adolescent population:
Impaired Glucose Tolerance: 12 million
Type 2 Diabetes: 4 million
Hypertension: 27 million
Hepatic Steatosis (fatty liver disease): 38 million (Lobstein & Jackson-Leach, 2016).
The study cautions global healthcare providers on these staggering numbers and their implications on the healthcare system around the world.
The associated co-morbidities of obesity are well-documented (Pantalone et al., 2017). Diabetes, heart disease, hypertension, dyslipidemia and kidney disease are just some of the examples of these serious co-morbidities.
Diabetes: Dr. Margaret Chan, Director-General of the World Health Organization (WHO) in 2016, said, “diabetes is one of the biggest global health crises of the 21st century” (Chan, 2016). Healthcare researchers and providers are saying that America is experiencing both a diabetes and an obesity crisis. In addition to having a serious effect on blood sugar, “diabetes and obesity are the main metabolic drivers of peripheral neuropathy” (Callaghan et al., 2018, para. 4).
Hypertension: Obesity is a known risk factor for hypertension (Hall et al., 2014). One source cites as much as 65%-75% of adult essential hypertension cases are a result of excess weight (Hall, Do Carmo, Da Silva, Wang, & Hall, 2015). The good news is that basic lifestyle modifications such as diet and exercise can drastically reduce hypertension in obese adults and, for some, reduce or eliminate the need for medication (Gorostegi-Anduaga et al., 2018).
Heart Disease: An analysis of 20 studies revealed that heart disease was the lead underlying cause of death in those with Class III obesity (Apovian, 2016).
A 2017 article discussed how higher weight and body mass actually decreased the responsiveness of the common anti-platelet drug, aspirin (Patrono & Rocca, 2017). Aspirin is an important drug in the care of many conditions, including treatment of a potential heart attack. While obesity itself increases risk of a heart attack, to think that the essential aspirin given at the onset of chest pain may be less effective is a scary, but real, thought. It is promising, however, that bariatric surgery is demonstrating some improvement in aspirin responsiveness, according to a study (Norgard, Monte, Fernandez, & Ma, 2017).
Kidney Disease: A 2017 article in the Canadian Journal of Kidney Health and Disease states, “a high body mass index is one of the strongest risk factors for new-onset chronic kidney disease CKD” (Kovesdy, Furth, & Zoccali, 2017, para. 1). Additionally, there have been numerous studies linking obesity, hypertension, and the development of kidney cancer as well as disease (Sanfillipo et al., 2014).
Osteoarthritis: The fact that obesity is a significant risk factor for the development of osteoarthritis is exceptionally bad, because with osteoarthritis comes joint pain. Joint pain can be often severe and can make a person avoid basic physical mobility, especially the exercise needed to lose the weight. The Arthritis Foundation states, “Every pound of excess weight exerts about 4 pounds of extra pressure on the knees” (Kane, n.d., para. 7).
NASH/NAFLD: According to The NASH (non-alcoholic steatohepatitis) Education Program, a study “based on a population with severe obesity (BMI > 40), more than 90% of individuals had (non-alcoholic fatty liver disease) NAFLD” (The NASH Education Program, 2018, para. 3).
Stroke: There are discrepancies among experts surrounding the idea of obesity being a direct risk for stroke. It is proven, however, that complications resulting from obesity (such as hypertension) do increase risk for stroke (Kernan & Dearborn, 2015).
Cancer: A UK study found that approximately 25% of adults were aware of the causative link between overweight, obesity and cancer risk (Cancer Research UK, 2017). “Excess body weight has been causally linked to an increased risk of ten different cancer types, including cancer of the esophagus (adenocarcinoma), colorectum, gallbladder, pancreas, liver, breast (post-menopausal), ovary, endometrium, kidney and prostate (advanced stage)” (Arnold et al., 2016, para. 1). Additionally, another study found that not only do obese post-menopausal women have an increased chance of developing breast cancer, but for every ten-year duration of overweight, the risk of developing endometrial cancer rises to 17% (Arnold et al., 2016). While not all carcinogens can be entirely avoided or risk of developing cancer eliminated, maintaining a healthy weight has shown to have a significant impact.
Research is also looking at not just obesity’s role in cancer development, but the factor of age as well. A large scale analysis of related studies reported that obesity in young adults (ages 18-21 years of age) “had a stronger influence on pancreatic cancer mortality” compared with those who became obese later on in life (Arnold et al., 2016). Age, length of time one is obese, and class of obesity all play important roles in disease development and all-cause mortality risk (Arnold et al., 2016).
Infertility
Ovarian function can be altered by obesity and its associated problems, such as hyperinsulinemia and hyperandrogenemia (Özcan Dağ & Dilbaz, 2015). This can lead to problems with conception, increase miscarriage rates, and other problems with fertility for obese women, especially those with polycystic ovarian syndrome (PCOS) (Silvertris, De Pergola, Rosania, & Loverro, 2018). Studies have found that weight loss has a significant impact on improving fertility for women with PCOS (Cox, 2016). One study compared PCOS patients who were treated with the fertility medication clomiphene and patients who participated in a weight loss and lifestyle modification program prior to clomiphene treatment. The results showed that those who lost weight prior to fertility treatment had an increase in both ovulation rate and live birth rate, compared with the group who only took the medication (National Institute of Health [NIH], 2016).
Dementia: Current evidence suggests a connection between obesity and the development of dementia(Anjum, Muniba, Wajid, Wafa, & Ali, 2018). Obese individuals have an increased amount of adipokines. Links have been made between the increased amount of adipokines in obese individuals and decreasing white matter in the brain (Anjum et al., 2018). Additionally, changes in blood flow in obese individuals may also play a role in the development of dementia (Anjum et al., 2018). One 2018 literature review discusses the impact of increased consumption of carbohydrates and saturated fat, typical in the obese, on cerebral glucose metabolism (Anjum et al., 2018). Inflammation and cerebral insulin resistance appear to play a big role in the connection between obesity and dementia (Anjum et al., 2018)(Sripetchwandee, Chattipakorn, & Chattipakorn, 2018). It is important to note that research is still being conducted in this area, as there are some studies with conflicting information surrounding obesity’s impact on dementia development, although those studies are not without limitations.
Mental Health and Obesity
More research is needed surrounding the correlation between mental health and obesity. One study did find, unsurprisingly, that with obesity came more “mental distress”, compared with those who were not obese (Jung & Chang, 2015). Issues such as stigma, physical limitations, pain, and financial burden of increased healthcare costs are all potential concerns of the obese. Mental health issues such as depression, anxiety, attention-deficit-hyperactivity disorder, and attempted suicide have been cited as being evident in young adult patients with severe obesity (Dreber, Reynisdottir, Angelin, & Hemmingsson, 2015).
The connection between mental health and obesity cannot be denied. Both can cause the same detrimental effects and decrease one’s quality of life. The existing concerns of disability, morbidity and mortality significantly increase when these two problems co-exist (Avila et al., 2015). The World Health Organization reports depression as being one of the leading causes of global disability (Abdelaal, Le Roux, & Docherty, 2017). One study estimates that “25%-30% of obese patients seeking bariatric surgery show marked clinical symptoms of depression” (Abdelaal et al., 2017, para. 25). Additionally, research indicates that even after bariatric surgery, body image concerns are very common (Perdue, Schreier, Swanson, Neil, & Carels, 2018).
The cycle of depression and obesity can be difficult to get out of. If depression can lead to weight gain, and having gained weight increases depression and robs the motivation and energy to exercise, it becomes a vicious cycle.
Research continues to be done on the connections between mental illness and obesity. One 2018 study reported that early-pregnancy maternal overweight and obesity had a significant impact on depressive symptoms (Kumpulainen et al., 2018).
Costs of Obesity
The costs of obesity reach far beyond the obvious. According to the CDC, obesity’s impact on the Armed Forces is growing (CDC, 2018). The data shows that as many as 16.5 million women and 5.7 men who are eligible for enlistment became ineligible due to their weight and body fat. (CDC, 2018). It may be something that doesn’t cross our minds every day, but this significant impact needs to be acknowledged.
Sources estimate approximately $2.0 trillion dollars was the global financial impact of obesity in 2014 (Tremmel, Gerdtham, Nilsson, & Saha, 2017). But the economy isn’t just affected by obesity in dollars and cents. Loss of productivity, lost work days, and increased risk of permanent disability are just some of the ways obesity can impact the economics of our country – as well as the citizens.
According to the American Diabetes Association, the cost of diagnosed diabetes in 2017 was $327 billion, with an average healthcare expense cost to each diabetic patient of over $16,000/year (American Diabetes Association [ADA], 2018). While not every patient with diabetes is obese and vice versa, it is important to consider the cost of diabetes when discussing the financial impact of obesity.
The most important cost, however, is the number of lost lives due to this preventable epidemic. Premature, all-cause mortality has been directly correlated with increased BMI (Aune et al., 2016).
Treatment of Obesity
The treatment of obesity requires a comprehensive, multi-focal, holistic approach. Factors ranging from community, mental health, genetics and lifestyle all play an important role. There is no one-size-fits-all answer for the treatment of obesity, and each patient should be treated as an individual and their specific risk factors addressed. The literature states, “Achieving sustainable weight loss requires comprehensive strategies that support patients’ efforts to make significant lifestyle changes” (Massetti, Dietz, & Richardson, 2017, para. 7). These lifestyle changes involve often drastic changes to diet and physical activity. But to achieve these changes, many other changes need to be made first.
Interventions at Home
Those trying to make a lifestyle change to combat obesity often need to decrease the amount of meals at a restaurant and/or take-out and begin cooking more at home. This takes time and could be more financially expensive than fast food. However, the physical toll fast food takes on the body makes the effort well worth it.
Busy schedules may need to be made even busier. Time needs to be dedicated to physical activity, whether it is a long walk or a trip to the gym. More time will be spent grocery shopping and preparing food. “Meal prepping”, or making meals prior to when they will be eaten, is a habit of many who strive to eat healthier. Instead of grabbing something from the work cafeteria or vending machine, lunches should be prepared at home prior. But once again, this takes time and a concentrated effort.
Specific recommendations for exercise vary and a physician should always be consulted before beginning every exercise program. In general, American Heart Association (AHA) guidelines suggest “30-60 minutes of moderate intensity aerobic physical activity, like brisk walking, done nearly every day” (American Heart Association [AHA], 2014, para. 5).
Interventions at the Community Level
Community level interventions have been proven effective, especially in the uninsured population and those in a lower socioeconomic status (Ahn et al., 2017). There has been an identified link between community resources and improved “family-centered” outcomes for childhood obesity, including improved BMI (Taveras et al., 2017). One program called Taking Steps Together comprised of “16 weekly 2-hour classes including educational activities, group cooking/eating, and physical activities for parents and children” (Anderson, Newby, Kehm, Barland, & Hearst, 2014, para. 1). Offering these programs at community locations such as recreation centers have been proven as accessible and effective for urban community families (Heerman et al., 2018).
Medical Interventions
There are a variety of medical related interventions for obesity. Medications, surgeries and diet plans are all available, but most come with additional risk. One 2018 study of 1888 patients found that bariatric surgery did improve outcomes related to co-morbidities of obesity, such as diabetes and hypertension. However, the study also found that these surgeries presented significant risk of serious complications (Jakobsen et al., 2018). While weight loss surgery can be life-saving for some, it is not a guarantee of sustained weight loss success. Research indicates between 21%-29% of lost weight was regained, and over one-third of patients who underwent Roux-en-Y gastric bypass experienced “excessive” weight gain down the road (Cooper, Simmons, Webb, Burns, & Kushner, 2015).
Orlistat, liraglutide, naltrexone/bupropion and locaserin are all examples of prescription medications that are used for weight loss (Leahy, 2017). While there is no “magic pill” for weight loss, these work in different ways to help aid the weight loss process. As with surgery, these do not come without risks and are not for everyone. There are specific Food and Drug Administration (FDA) regulations for those medications that are marketed as “weight loss medications” (Leahy, 2017). Some of these medications also assist with managing associated co-morbidities such as diabetes. For example, liraglutide works on managing blood sugar and insulin levels (Leahy, 2017). Medications should always be used with caution and only in combination with other lifestyle modifications such as diet and exercise.
Summary
Obesity and its co-morbidities are an epidemic in America. It has become a complex, expensive and dangerous problem. Ultimately, the answer is not in expensive surgeries or fad diet pills. A well-balanced, healthy diet and regular aerobic exercise are key for preventing and treating obesity and its co-morbidities. Nurses can make an impact on this serious epidemic through patient education, advocacy and community involvement.
References
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