Tools
Public Health Considerations Regarding Obesity
Introduction
Obesity is increasing as a global public health issue. It affects 2 in 5 adults and 1 in 5 children in the United States and has been characterized as an epidemic.[1][2][3] Several countries worldwide have witnessed a doubling or tripling in the prevalence of obesity in the last 3 decades (see Images. Obesity Trends in Children and Obesity Trends in Adults), likely due to urbanization, sedentary lifestyles, and increased consumption of high-calorie processed foods.[4]
The alarming increase in childhood obesity forecasts a significant burden of chronic disease worldwide. Obesity prevention is critical in controlling obesity-related noncommunicable diseases (OR-NCDs), including type 2 diabetes, insulin resistance/metabolic syndrome with hyperinsulinemia, hyperlipidemia, hypertension, metabolic-associated fatty liver disease, and coronary artery disease.[5][6]
The failure of traditional obesity prevention and control measures underscores the need for a new, nonstigmatizing public health policy model. This approach shifts the focus from solely targeting individual behavior changes to implementing strategies that address broader environmental factors contributing to obesity. Weight bias and discrimination against people with obesity exist in public settings, eg, workplaces, healthcare facilities, and schools, and must be confronted on a societal level.
Issues of Concern
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Issues of Concern
Public Health Impact of Obesity
Obesity is a growing global public health challenge with far-reaching effects on individuals and society. The public health impact of obesity extends beyond physical health, influencing life expectancy and quality of life and contributing to economic and employment burdens. The following are the various impacts of obesity on individual and public health:
- Life expectancy: Obesity causes serious illness and decreases the average life expectancy. Adult obesity strongly predicts early death. The Framingham Heart Study, a prospective cohort study, revealed that adults who were obese at 40 years lost 6 to 7 years of their expected lifespan. However, in obese people who smoked, the years of life lost almost doubled.[7][8]
- Quality of life: Obesity affects both the physical and psychosocial aspects of quality of life, even more significantly in individuals with class 3 obesity. The subjective Health-related quality of life (HRQL) assessment among individuals with obesity worsens with increasing body mass index (BMI). The effect of obesity on HRQL is assessed most often by the Short-Form Health Survey, comprising 36 questions covering 8 domains, including physical functioning, physical limitations in daily activities, social functioning, bodily pain, general mental well-being, limitations due to emotional problems, energy levels and fatigue, and overall perception of health.[9][10] The risk of a chronic medical condition nearly doubles in people with class 3 obesity compared to individuals with overweight.[11] Obesity causes a substantial psychological burden exacerbated by society's preoccupation with thinness. Sullivan et al reported more significant psychosocial consequences in women with obesity than in men.[12]
- Prevalence of obesity-associated diseases: Individuals who are obese in childhood tend to remain obese in adulthood and are prone to OR-NCDs at a younger age.[13] These include type 2 diabetes, coronary artery disease, stroke, cancer, asthma, and chronic obstructive pulmonary disease, which have increased worldwide along with the prevalence of obesity. These conditions are the primary targets of the World Health Organization (WHO) global disease prevention.[14] Compared with their healthy-weight peers, individuals with class 2 obesity lose about 8 disease-free years of life, and those with class 1 obesity lose about 4 disease-free years.[15]
- Employment: Obesity is one of the leading reasons for discrimination in the hiring process, more among women than men.[16] Obesity can lead to underemployment and an increase in self-reported work limitations compared to healthy-weight individuals.[17]
- Economic impact: Obesity and its complications account for greater than 20% of annual healthcare expenditures in the United States.[18][19] Medical costs are 30% to 40% higher among individuals with obesity than their healthy-weight peers, double the increase attributable to smoking.[20] The direct costs of obesity include spending on diagnosing and treating obesity and obesity-related chronic comorbid conditions, eg, cardiovascular disease and type 2 diabetes. Indirect costs arise from lost wages due to illness and premature death, higher expenses for disability and insurance claims, and reduced productivity at work.
- Physical functioning: Obesity can impair the ability to perform physical activities, including mobility and activities of daily living.
- Physical health: Physical health problems associated with obesity can limit individuals' ability to perform expected tasks at work or at home.
- Mental health: Mental health issues (eg, anxiety or depression) can affect the ability to perform work or daily activities. Emotional well-being, including happiness, anxiety, and overall mood, can impact those with obesity at higher rates than their healthy-weight peers.
- Social functioning: The ability to engage in social activities and interact with others can be diminished.
- Bodily pain: The Intensity of pain can impact daily functioning.
- Energy: Decreased energy level or fatigue may impair daily functioning.
- General health perceptions: Overall perception of health, including current health status and future outlook, may be appropriately low in individuals with obesity.
Clinical Significance
The WHO describes obesity as excessive fat accumulation. A body mass index BMI ≥25 kg/m2 is considered overweight, and a BMI ≥30 kg/m2 is labeled obesity. The relative risk of death increases with increased BMI. This association is nonlinear, with a higher relative risk of death for individuals with a BMI greater than 30 kg/m².[21]
The stigma of obesity deters individuals from utilizing healthcare resources that could prevent morbidity and identify complications early. For example, people with obesity have lower rates of age-appropriate preventive cancer screening.[22][23] Women with obesity delay accessing routine gynecological cancer screening due to perceived social barriers.[24] This reduction in preventive healthcare adds to the burden of morbidity and all-cause mortality. A lack of comprehensive health maintenance care imposes an additional burden on the healthcare system to manage the comorbidities of obesity, which might have been prevented.
Other crucial issues likely affect the obesity burden, including perinatal factors, eg, maternal antenatal BMI, neonatal birth weight, child nutrition in the first 3 years of life, infant feeding choices (breastfeeding versus formula feeding), and the growth pattern in the first year.[25]
Other Issues
Assessing and addressing the barriers that patients with obesity face, which delay obtaining recommended preventive healthcare, is imperative. Health and social inequalities result when efforts to prevent obesity are impaired.[26]
Public Health Policy and Environmental Changes
Societal and environmental changes are the best initiatives for preventing the burden of obesity. Public policy initiatives that can be implemented to change behaviors, leading to healthier dietary and exercise choices include:
- The Food and Drug Administration (FDA) has issued regulations mandating calorie and nutrition labeling in all food products.
- In 2015, the FDA officially banned trans fats in all food in restaurants and grocery stores.
- Obesity prevention priorities can focus on children, particularly in schools, encouraging healthy habits. Local governments can restrict commercial permits for fast-food restaurants near schools (within 0.5 miles) and promote healthy foods in school meals.[27]
- School policies should mandate physical education classes and develop plans for safe ways to walk or bicycle to school.
- Levying taxes on unhealthy food and subsidizing healthy choices are strategies to prevent obesity but may encounter ethical limitations regarding personal choice. Taxes on sugar-sweetened beverages, eg, soft drinks, have been successfully levied in many states and cities.[28][29]
- Public health policy can focus on designing activity-friendly communities by creating bike and walking paths and safe green spaces for outdoor activities.
Family-Based Interventions
The family-based approach is the best intervention to sustain weight loss and weight maintenance among patients with overweight or obesity. Often, several members in a household would benefit from weight loss, and individuals find it challenging to change their lifestyles without family cooperation and support.
No one weight-loss diet has been proven superior. Some studies advocate a low-fat diet with high protein and low glycemic index foods to maintain weight loss and prevent weight regain.[30][31] Other plans include the Mediterranean or DASH diets, intermittent fasting, or a ketogenic diet. 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 based on health benefits.[32] Whatever the strategy, success depends upon ongoing support and close follow-up to ensure an appropriate plan for each family.
Weight Bias in Health Care
Weight bias in health care can be explicit (consciously expressed) or implicit (involuntarily expressed). Implicit weight bias is not rare among clinicians, as society's negative biases towards overweight and obesity are often shared and exhibited by caregivers (see Image. Impact of Weight Bias). This weight bias can impair the quality of health care. Many clinicians promote the energy balance theory of weight control, believing that obesity is the fault of an individual, which limits effective counseling and intervention.[33][34] The following recommendations can reduce weight bias in healthcare:
- Educate healthcare professionals about the complex etiology of obesity, including genetic, metabolic, environmental, and social factors.
- Inform clinicians that weight bias negatively influences the quality of care.
- Train students in healthcare professions to communicate without implicit bias.
- Another strategy is to expose counter-stereotypical exemplars of people with obesity who are successful and intelligent.
- Address patients' overall health, addressing their understanding of obesity-associated comorbidities and desire for weight loss management.
- Use people-first language, eg, "patients with obesity" instead of "obese patients." Objective terminology, including "high BMI" or "class 1, 2, or 3 obesity," rather than descriptions, eg, "morbid obesity," shows respect and promotes communication in clinical settings.
Enhancing Healthcare Team Outcomes
Addressing obesity effectively requires a coordinated, interprofessional approach to patient-centered care. Primary care physicians play a crucial role in diagnosing obesity, monitoring weight and BMI, and encouraging preventive screenings during health maintenance visits. Nurses, nurse practitioners, and physician assistants are essential in providing follow-up care, supporting patients, and motivating families to adopt healthier lifestyles. Dietitians develop personalized nutrition plans that consider cultural preferences and coexisting health conditions, while exercise specialists recommend age-appropriate physical activity for individuals and families. Behavioral counselors address psychological factors that contribute to maladaptive eating patterns, and school-based health groups support children with obesity and emotional challenges.
For pediatric obesity care, consultation with specialists such as pediatric endocrinologists, obesity experts, and surgeons may be necessary. Public health policymakers play a pivotal role in creating nonstigmatizing, preventive strategies to address the global obesity epidemic. Collaboration among clinicians, policymakers, and community resources is vital to reduce barriers to treatment and ensure welcoming, accessible healthcare environments for individuals with obesity. This interprofessional coordination enhances patient safety, care quality, outcomes, and overall team performance, ultimately addressing the complex public health challenge of obesity.
Media
(Click Image to Enlarge)
Obesity Trends in Children. Graph demonstrating the rise in obesity in children and adolescents.
Centers for Disease Control and Prevention
(Click Image to Enlarge)
Obesity Trends in Adults. Graph demonstrating the rise in obesity in male and female adults.
Centers for Disease Control and Prevention
(Click Image to Enlarge)
Impact of Weight Bias. Many clinicians promote the energy balance theory of weight control, believing that obesity is the fault of an individual, which limits effective counseling and intervention.
Contributed by P Balasundaram, MD
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