Depression and obesity: comparative analysis and health implications

OBESITY 1
OBESITY 15








Obesity
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Introduction
Obesity is a global epidemic affecting almost all population cohorts. Rates of obesity are rising worldwide. According to the World Health Organization (WHO, 2013), the obesity epidemic “is not restricted to industrialized societies,” with millions of obesity-related cases burgeoning in developing countries (p. 1). With billions of cases worldwide, obesity has therefore been described as the “major health hazard of the 21st century,” (Zhang, Liu, Yao, et al., 2014, p. 5153). Given the global nature of the disease, clinical guidelines have become increasingly standardized, but it is still necessary to tailor interventions to specific populations to create age appropriate, culturally appropriate, and gender appropriate treatment interventions. After a brief discussion of obesity pathophysiology, this paper will evaluate standard practices at local, state, national, and international levels. Access to care and treatment options also determine disease outcomes. Therefore, this paper will also address the core factors involved in public health strategies and health policy.
Pathophysiology
Defined clinically as “an exaggeration of normal adiposity,” obesity is the condition of being excessively overweight based on quantitative measures like body mass index (BMI) (Redinger, 2007, p. 856). However, the pathophysiology of obesity is also linked to ancillary factors like metabolic and immune dysfunction. BMI alone is not a reliable assessment measure either, due to individual differences (Li & Cheung, 2009).
The biggest health-related problem with obesity is its comorbidity with a number of potentially fatal conditions including diabetes, heart disease, and cancer (Zhang, Liu, Yao, et al., 2014). Obesity is a complex problem linked to a number of variables, but lifestyle is typically implicated given that “overconsumption of calorie dense foods” is a known culprit in disease etiology (Zhang, Liu, Yao, et al., 2014, p. 5153). Increased availability and low cost of calorie dense foods has contributed to the proliferation of obesity, but there are also physiological and neurological factors that contribute to disease progression. Due to biological or genetic reasons, some individuals do seem predisposed towards obesity based on neuroimaging (Zhang, Liu, Yao, et al., 2014). Therefore, obesity is a result of both genetic and lifestyle factors, and a biopsychosocial approach to treatment interventions may be warranted in most cases.
Standard Practices
Standard practices involve preventative and ameliorative treatment interventions. Interventions may include individual interventions and also community or public health interventions including public policy and legislation. The Centers for Disease Control and Prevention (CDC, 2017), for example, offers public health strategies like building communities conducive to physical activity and removing barriers to healthy eating. Community practices coincide with primary care interventions, which include regular and ongoing assessments of risk status, assessment of patient attitudes and lifestyle, dietary and lifestyle recommendations, and also pharmacological interventions.
Pharmacology
Especially at the preventative and early intervention stages, obesity can be managed through lifestyle changes alone. When the disease has progressed, however, and when genetic or biological factors are involved in the persistence of the disease, pharmacological interventions may be warranted or necessary. Research shows that pharmacological interventions combined with lifestyle changes are more effective than lifestyle changes alone for some patients (Li & Cheung, 2009). However, the global healthcare community understands that pharmacological interventions alone are rarely efficacious in disease maintenance and that medications need to be combined with dietary and physical activity interventions (Apovian, Aronne, Bessesen, et al., 2015). Currently, there are only two medications that have been approved in the United States for the long-term management of obesity: Sibutramine and orlistat (Li & Cheung, 2009). The former reduces appetite to help the patient reduce food intake more reliably, while the latter is a drug that acts as a gastrointestinal lipase inhibitor, effectively interfering with fat absorption to prevent weight gain. (Li & Cheung, 2009).
Assessment and Diagnosis
The National Institutes of Health (2000) offer a practical guide for healthcare practitioners for standardized obesity assessment and diagnosis procedures. In addition the BMI measurements, the guide includes instructions for measuring waist circumference and testing for specific comorbidities like diabetes and blood pressure. Assessment and diagnosis procedures also entail differentiating between overweight, as a precursor and risk factor of obesity, and obesity itself. However, “there is no precise clinical definition of obesity based on the degree of excess body fat that places an individual at increased health risk,” (Lyznicki, Young, Riggs, et al., 2001, p. 2185). Measuring BMI is an “inexpensive” measure that can at least help physicians make recommendations and encourage further testing of patients who are deemed at risk for developing health problems as a result of being overweight or obese (Kushner, 2012). Subsequent to diagnosis, healthcare teams should offer patients a range of options based on their current lifestyle and their willingness and ability to change. Unfortunately, “national studies have shown that obesity counseling rates remain low among healthcare professionals,” (Kushner, 2012, p. 2870). Even if assessment and diagnostic procedures remain complex and individualized, healthcare workers need to develop more comprehensive protocols for treatment intervention plans. Assessments are also based on patient risk factors for developing comorbid conditions (National Institutes of Health, 2000).
Patient Education
Patient education is the cornerstone for obesity awareness, early detection, risk management, and treatment. Yet there is no national standard for patient education, and also no established local or state program for patient education on obesity. Instead, there are a plethora of public awareness campaigns that often fail to target structural and socioeconomic issues that are major factors in disease progression, such as the lower cost of calorie-dense and nutritionally vacant food products, or the overall sedentary lifestyle practiced by an increasing number of people worldwide. Overall awareness of the problem of obesity is high, but compliance with recommended interventions can be astonishingly low due to a multitude of factors including weaknesses on the part of the healthcare team to properly communicate and educate clients (Kushner, 2012). It is important to frame patient education in ways that are culturally appropriate but also sensitive to the need to avoid stigmatizing and judging patients based on their appearance (Kushner, 2012). Yet political correctness should not override the need for patient education, particularly as obesity is preventable yet presents a tremendous cost burden to all affected societies (Li & Cheung, 2009). It is therefore an ethical objective to commit more to patient education and obesity prevention.
Local, State, and National Practice Alignment
Because obesity is a multifactorial disease, there is an understandable lack of standard guidelines. Aligning local, state, and national practices would help healthcare workers come up with consistent and comprehensive interventions that are still adaptable to target populations. The CDC (2017) offers suggestions for local, state, and federal officials to implement prevention strategies including education-based interventions that prevent childhood obesity. Likewise, the CDC (2017) encourages standard practices for early childhood obesity risk factor identification and nutritional and lifestyle counselling. Standard practices for obesity management in this community does align generally with state and federal policies, each of which recognizes there is a problem and understands the wealth of evidence showing how obesity is linked to a number of comorbid conditions that are essentially preventable.
Effective Disease Management
Effective disease management for obesity depends on a number of critical factors, including the patient’s overall health status, socioeconomic demographics, geography, culture, lifestyle, and overall commitment to health. To effectively manage obesity, the patient needs to demonstrate readiness and willingness to change and a commitment to long-term changes to diet and exercise habits. Compliance with recommended health behaviors will effectively manage symptoms and prevent complications.
Access to Care and Treatment Options
Access to care may prevent a large number of at-risk and obese patients from seeking medical attention and receiving education. Barriers to care may include the fear of stigma, causing some obese patients to avoid seeing their doctors until a health problem has progressed. On the other hand, a patient who deftly manages their symptoms will have improved health outcomes including longer life expectancy and reduced risk for comorbid conditions. Access to care also includes access to treatment options that go beyond just dietary and lifestyle factors. For example, the patient needs to have access to a team of healthcare workers who are knowledgeable about the latest pharmacological interventions and other evidence-based practices that can help reduce symptoms and promote health and wellbeing. Successful disease management is not just about losing weight but about maintaining a healthy body weight and reducing risk factors for heart disease, diabetes, and other comorbid conditions.
Access to care and treatment options also have geographic, cultural, and socioeconomic implications as well. Patients living in communities where healthy lifestyles are normative are more likely to participate in healthy behaviors versus their counterparts in communities without access to healthy choices. Research shows that in low income neighborhoods where calorie dense foods like fast foods are more readily available than healthy foods, patients were still unlikely to change their eating habits when exposed to healthy options (Cummins, Flint & Matthews, 2014). The reason for their lack of lifestyle change was due to overarching variables like social norms. Therefore, accessibility of interventions needs to be coupled with overall awareness, education, and normative changes in the society. A patient who manages obesity effectively is one who may need to be positively deviant, in the sense of diverging from community-level norms in a healthy way.
Life Expectancy and Other Outcomes
Because of intervening variables, there is no way to predict for certain whether managing obesity will lead to longer life expectancy. However, obesity has been empirically linked to enough comorbid disease conditions and lower life expectancy that it can be assumed that managing obesity will at least reduce risk for premature death or preventable disease. Therefore, a person who manages their symptoms consistently and as soon as possible will enjoy better overall health outcomes. Additional benefits to the patient may be increased self-efficacy and other psychological benefits to disease management.
National Versus International
There are disparities in disease outcomes, and between management of obesity on a national and international level. Disparities usually manifest along socioeconomic or ethnic lines (Lewis, Edwards-Hampton & Ard, 2016). Furthermore, there are recently emerging disparities between disease management between the United States and other countries. Those disparities are linked to the greater social disparities tabulated within the United States versus European countries (Van Hedel, Avendano, Berkman, et al., 2015). Americans have higher mortality rates as a result of obesity, something that researchers are starting to attribute more to disparities in education and intelligence (Van Hedel, Avendano, Berkman, et al., 2015). More successful outcomes for disease interventions depend on improving the overall educational outlook for Americans, improving patient education, and transforming the culture from being one that celebrates ignorance to one that embraces science. As much as education and intelligence matter, though, some cases of obesity remain stubborn, linked more to biological factors that warrant additional interventions that could include pharmacological treatments. Those treatments do need to be made available equitably among various population cohorts.
Contributing Factors
Obesity is a complex and multifactorial disease. Four factors that contribute to the patient’s ability to manage obesity include financial resources including insurance coverage, access to care, genetics, and culture.
Financial Factors
Obesity is a disease that cuts across multiple socioeconomic demographic groups. Financial incentives for eating healthier food or reducing intake of unhealthy food have been found to be ineffective (Sturm & An, 2014). However, financial resources do factor into obesity management and health behaviors. Children in low-income households are at a far greater risk than their more privileged counterparts for becoming obese (Bomberg, Birch, Endenburg, et al., 2017). Financial disparities do not cause obesity, which is a problem across all socioeconomic groups, but financial disparities may have a strong bearing on disease treatment and health-seeking behaviors subsequent to diagnosis.
Financial factors are linked to the patient’s insurance status and ability to afford interventions or necessary lifestyle changes. For example, patients without insurance may not have the ability to pay for pharmacological treatments that might help supplement their dietary and lifestyle changes to bring about long-term results for disease management. Patients from lower socioeconomic demographics may also live in areas where walking or cycling to work is not possible, or where time constraints prohibit their ability to consume healthy foods. Being underinsured also decreases the likelihood that a patient will receive early diagnoses, ongoing health assessments, and quality care. Even with an abundance of financial resources, though, obesity is a disease in which patients ultimately need to take action and manage their behavior and lifestyle.
Access to Care Options
Access to care options has been a factor influencing disease etiology and progression. For example, urban design and accessibility to avenues for exercise can be considered a health access issue (Sturm & An, 2014). Patients living in rural communities may also have less access to quality medical care interventions, particularly at the preventative stage. Access to care is also linked with financial variables. Financial strain impedes the ability of patients to seek medical treatment, pay for pharmacological and other interventions, and invest in necessary lifestyle changes.
Genetics
Some patients are genetically predisposed towards obesity, making the dietary and lifestyle changes less effective at long-term disease management. For example, Prader-Willi syndrome (PWS) is a “genetic imprinting disorder that results in profound hyperphagia and early childhood onset obesity,” (Zhang, Liu, Yao, et al., 2014, p. 5153). Early intervention is critical, prior to onset of obesity because of the way the body’s metabolism changes dramatically after the patient maintains an obese state for a long period of time (Redinger, 2007). In fact, genetics can be a major factor precluding patients from seeking further treatment, and can have adverse impacts on health outcomes as patients predisposed towards obesity may become frustrated when their health behaviors do not yield desired results. When addressing the needs of patients who are biologically or genetically predisposed to obesity, healthcare workers need to be more conscientious about offering the pharmacological aids that can assist with persistent weight management and for the mitigation of ancillary diseases.
Unmanaged Care Outcomes
When obesity is not managed as a healthcare concern, it can cause or exacerbate several health problems including hypertension, diabetes, and some types of cancer. Obesity can also cause or exacerbate mental health conditions like anxiety or depression. As Redinger (2007) also points out, obesity suppresses immune system responses and “has the potential to be profoundly detrimental to our species if major methods of prevention and/or effective treatment are not realized,” (p. 856). If the disease is left unmanaged, the effects reverberate within families and communities. Obesity can also be framed as a public health concern in the sense of its overall cost burden to the taxpayer (Li & Cheung, 2009). As Van Hedel, Avendano, Berkman et al. (2015) also point out, unmanaged obesity has raised overall mortality rates in the United States especially.
Community-Level Issues
This community is no different than any other in the United States, with a high enough prevalence rate to warrant closer attention and more comprehensive public health interventions. Obesity affects individual patients, in terms of their physical and psychological health. In fact, obesity also impacts patients’ social functioning and in some cases, financial functioning due to stigmas related to being overweight in the society. Obesity also impacts social systems within the community, at the micro-level of the family as well as the mezzo-level of neighborhood and organization. Community rates of obesity also have a strong bearing on how health resources are allocated. Obesity diverts needed funding from other diseases, and also diverts healthcare human resources. From diagnosis to treatment, from prevention to intervention, the costs associated with obesity management in the community are tremendous.
As Tremmel, Gerdtham, Nilsson, et al. (2017) point out, “obesity also imposes a large economic burden on the individual, and on families and nations,” (p. 435). In addition to burdening the healthcare system with what is in most cases a preventable problem, obesity also results in losses in productivity with potential net losses to the local economy. Some obese individuals develop health problems that prevent them from being able to perform at work, or problems that lead to premature death. The personal costs associated with obesity and related treatments also hurt the patient and the family, as few insurance policies will cover every aspect of the obesity care interventions. As a result, obesity is restricting access to what would have been patients’ disposable income that could be used for life-affirming activities such as travel and hobby pursuits. Obesity can also impede the ability of a person to enjoy physical activity, as being overweight reduces cardiovascular performance due to the increased strain placed on the body. Prescribed physical activity may instead be pursued more as a chore or burden than as something that promotes pleasure. Persons who overeat on processed and junk foods also potentially derive far less pleasure from eating than they would if their diet consisted of fresh whole foods. Because of the wide range of social and financial problems associated with obesity, healthcare workers in the community need to play a more active role in disease prevention, patient education, advocacy, and outreach.
Promoting Best Practices
Promoting best practices involves teamwork and coalition building within the community, and between the community and external partners at the state, federal, and international levels. Both the private and the public sector have the potential to become robust partners in the health outreach goals. Best practices will include a combination of services and public health interventions. As much as possible, healthcare workers will rely on evidence-based practices and interventions in the healthcare organization.
Telehealth
Especially useful for practitioners in rural areas, or whose scope of practice includes rural, urban, and suburban areas together, telehealth options provide a meaningful and viable solution for overcoming barriers to treatment access. Telehealth options have been shown to be effective at helping patients in rural areas communicate with primary care practitioners, who can thereby monitor patient progress and field patient questions and inquiries in a non-invasive and convenient manner (Lewis, Edwards-Hampton & Ard, 2016). Telehealth removes access barriers related to cost and transportation services, and also appeal to patients with social anxiety and other psychological impediments to seeking care.
Telehealth interventions should not be limited only to rural regions. Patients in urban centers also need telehealth options for improved time management. Obesity is a disease that requires ongoing care, monitoring, and lifestyle changes. Therefore, patients with access to telehealth can monitor the progress of their disease better using technological tools that preclude the need for doctor appointments. Telehealth can also reduce cost burdens in healthcare, as using telehealth technologies over time can save money on in-person office visits for patients and healthcare organizations alike.
Operationalize Appropriate Interventions
It is strongly recommended that the healthcare organization operationalize its strategies for providing age appropriate and culturally appropriate interventions. While all interventions and treatment plans should be individualized, healthcare workers also need expressly outlined protocols and strategies that can be broadly applied to each patient cohort. Guidelines can be based on evidence compiled from focus groups and qualitative as well as quantitative data showing what works for each population. Operationalizing the appropriate interventions will illuminate which strategies work well and why, helping healthcare administrators to make adjustments and changes as necessary based on empirical evidence. Moreover, the operationalization of the interventions will also help administrators and healthcare workers to recognize risk factors more readily.
Increasing Advocacy and Outreach Efforts
Outreach involves working with schools and other community organizations to build bridges and increase public education about obesity. With a target of improving preventative care and preventing onset of the disease, outreach strategies can also include working with the private sector. Private sector partners can offer prevention programs for employees and also offer funding sources for the healthcare community. Patient advocacy, a cornerstone of nursing, includes communications strategies that reduce stigma related to obesity. Advocacy also includes helping patients who lack financial resources, by linking them with local organizations and institutions that can provide aid. Patients may, for example, be unaware of free exercise classes offered at a community center or recipes for quick and easy to prepare healthy meals they can make for their family at home. Advocacy also includes informing patients of their insurance options, for gaining access to coverage for treatments including pharmacological options for treating obesity.
Conclusions and Evaluations
Telehealth
Evaluating the efficacy of telehealth programs will depend on several measurement strategies including surveys designed to assess patient perceptions. In addition to tabulating patient perceptions and level of patient satisfaction with telehealth, it is also critical to measure actual performance outcomes. Performance outcomes for telehealth strategies will include measuring rates of obesity before and after, and also individual patient level changes such as reductions in BMI and other improvements in overall health measures such as lower blood pressure.
Operationalizing of Interventions
To measure the efficacy of operationalized interventions, population studies would be required. Both qualitative and quantitative measures would be useful. Qualitative measures would include case studies, interviews, and focus groups, whereas the quantitative measures would include surveys but also assessments of patient outcomes within the target population. As with the other assessments, measuring the effectiveness of operationalization would include within-patient changes to measurable health outcomes and also intra-population measures of overall effectiveness.
Advocacy and Outreach
Measuring the effectiveness of advocacy and outreach programs will involve qualitative assessments and also aggregate community data. Qualitative assessments will include interviews with strategic partners in the community, and patient perceptions of the types of outreach strategies that were being used. In addition to the qualitative assessment methods, the healthcare organization would also want to implement some quantitative measures that would enhance evidence-based strategies for the organization and community. With the right combination of interventions and strategies, obesity rates can be systematically reduced in the community.




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