By Traci Haynes, MSN, RN, BA, CEN
During the last three decades, the prevalence of individuals being overweight or obese has increased significantly in both the United States and globally. In June 2013, the American Medical Association (AMA) officially recognized obesity as a disease. It was reported as a move to both encourage physicians to pay more attention to the condition and spur more insurers to pay for treatments. To date, obesity remains an epidemic in America and internationally as reported by the World Health Organization (WHO). Due to the rapid increase in obesity prevalence and the serious public health consequences, obesity is considered one of the most serious public health issues of the early twenty-first century (WHO, 2012).
The Trust for America’s Health, funded by grants and dedicated to saving lives by making disease prevention a national priority, conducted a study over a decade ago to determine the effectiveness of government action against obesity. The first edition of their report, F as in Fat: How Obesity Policies are Failing in America, was published in 2004. It stated, “Obesity had become an epidemic in America, and is poised to become the nation’s leading health problem and No. 1 killer” (Trust for America’s Health, 2004). It reported that nearly 119 million American adults, 65 percent of the population were overweight or obese, causing 400,000 deaths per year (or 45 per hour) and would soon overtake tobacco use as the leading cause of preventable death. It also reported that the percentage of overweight children had more than doubled and adolescents had tripled since 1980 and that these younger generations may be the first in American history to live sicker and shorter lives than their parents.
There has been an updated report published every year, and in 2007 the Robert Wood Johnson (RWJ) Foundation became involved, investing over $500 million to reverse the childhood obesity epidemic. In 2014 the report was renamed “The State of Obesity.” And in 2015 the numbers are still staggering. However, there is starting to be some improvement especially concerning building awareness, improving nutrition, and increasing activity in schools and in the communities.
The State of Obesity website provides “Fast Facts” on adult obesity and related disorders, obesity in children and teenagers, physical activity, healthy food, and racial and ethnic disparities. These Fast Facts report the ten states with the highest adult obesity rates are in the South and Midwest and most of the states with the lowest obesity rates are in the Northwest or West. The states with the highest adult obesity rates (over 35 percent) are Arkansas, West Virginia, and Mississippi. Colorado has the lowest obesity rate at 21.3 percent and the lowest rate of physical inactivity at 16.4 percent.
There are twenty-two states with an obesity rate above 30 percent, forty-five states are above 25 percent and every state is above 20 percent. Historically, in 1980 no state had an obesity rate above 15 percent; and in 1991, no state had a rate above 20 percent. Now, nationally more than 30 percent of adults, nearly 17 percent of two to nineteen year olds, and more than 8 percent of children ages two to five are obese. Nine of the ten states with the highest rates of type 2 diabetes are in the South and all twelve of the states with the highest rate of hypertension are in the South. For children and teenagers, seven of the ten states with the highest obesity rates for ages ten to seventeen are in the South, while seven of the ten states with the lowest obesity rate for the same age range are in the West. The four states with the highest obesity rate also have the most adults who don’t exercise (State of Obesity, 2015).
Not only is obesity a public health issue in the United States, which has the highest rate of obesity in the world, but it is also a worldwide problem. The WHO reports that worldwide obesity has more than doubled since 1980. In 2014 more than 1.9 billion adults ages 18 or older were overweight with over 600 million being obese. And most of the world’s population live in countries where overweight and obesity kill more people than being underweight.
Obesity was once considered a high-income country problem. However overweight and obesity are now on the rise in low- and middle-income countries, particularly in urban settings. More than 50 percent of the world’s obese population live in ten countries, which includes the US, China, India, Russia, Brazil, Mexico, Egypt, Germany, Pakistan and Indonesia (WHO, 2015).
According to the National League of Cities, the estimated annual cost of obesity in the US is $190.2 billion. Obesity consumes nearly 21 percent of medical spending, and related job absenteeism equals $4.3 billion. Childhood obesity equates to $14 billion in direct medical costs (National League of Cities, 2015).
The Affordable Care Act of 2010 designated two recommended preventive services to be covered at no cost sharing to individuals. The first is dietary counseling for adults at higher risk for chronic disease; and the second is obesity screening and counseling for adults and children ages six and over. In November 2011, Medicare began covering intensive behavioral therapy for individuals with a BMI of 30 or more. Counseling may be covered if it is received in a primary care setting. It covers fifteen minutes of face-to-face individual behavioral therapy sessions or thirty minutes of face-to-group behavioral counseling sessions.
The food industry plays a significant role and could potentially be listed as a contributing factor to the obesity epidemic. Reducing the fat, sugar, and salt content of processed foods would help influence obesity, as would responsible marketing especially that aimed at children and teenagers. Ensuring healthy and nutritious food choices are available and affordable as well as supporting regular physical activity in the school and workplace is essential (WHO, 2015).
Obesity’s etiology is far more complex than simply an imbalance between energy intake and energy output, but this is how it is most commonly explained. In reality it is a complex disease with genetic, biological, economic, environmental, psychosocial, and behavioral determinants. Overeating relates to portion size, eating out, and eating fast food (less expensive), eating all day (a recent study reported many Americans eat fifteen hours per day and most of the calories are consumed after 6 p.m.), eating energy dense, or calorie rich foods, and eating disorders (bingeing, lack of satiety, food-seeking behavior, night-eating syndrome, etc.). Physical inactivity relates to a more sedentary lifestyle. Genetic syndromes such as Prader Willi and others, may affect hormones involved in fat regulation (e.g., a deficiency in leptin and the amount and areas of body fat storage).
Family history most often is attributed to the environment, but heredity can play a part in metabolic rate, spontaneous physical activity and thermic response to food. Age is another factor. As a person ages, there tends to be a loss of muscle mass. Also, physical activity often decreases, and since muscle burns (metabolizes) more calories there is a need for a decreased caloric intake. Foods specific to certain cultures and ethnic populations may be high in salt or fat.
Certain medications can also be a contributing factor, such as some anti-depressants, anticonvulsants, some diabetes medications, certain hormones like birth control pills, some antihypertensives, and most corticosteroids. Emotions influence eating habits, therefore psychological factors can also contribute. Environment plays a role in shaping habits and lifestyle. Driving instead of walking, increased technology for entertainment, and convenience foods have all had an impact on everyday life (Curry, K., Goldsmith, C., & Birn, C., 2015).
The two most commonly reported contributing factors to obesity is overeating and physical inactivity. Portion size today is two to eight times larger than the USDA or FDA standard. In 1955 a fast food restaurant introduced French fries with the original portion weighing 2.4 oz. and having 210 calories. Today, the large size of French fries is 7.1 oz. and has 610 calories. From 1982-2002 the average pizza size grew 70 percent. The average Caesar salad doubled in calories and the average chocolate chip cookie quadrupled in calories. Plate size has grown to hide the larger portions.
The surface area of the average dinner plate has expanded by 36 percent between 1960 and 2007 (Gunders, D., 2012). And the Cornell Food and Brand Lab reported that the serving sizes in the Joy of Cooking cookbook have increased 33.2 percent since 1996. A recipe that used to serve ten, now serves seven, or the ingredient amounts have been adjusted for the greater number of servings. Caloric density and a diet high in simple carbs and fats are also factors (Cornell University Food and Brand Lab, 2015).
Only about one-half of US adults meet the minimum guidelines for aerobic physical activity (150 minutes per week of moderate exercise or 75 minutes per week of vigorous exercise). Youth inactivity numbers are also accelerating, which results in increased health issues and cost. When school systems have to reduce expenses, physical education and sports are often cut back or eliminated. And research has shown inactive children don’t perform as well academically and that an inactive child will more than likely become an inactive adult. Video games and too much TV time is also socializing children to become inactive.
The most common complications and health risks associated with obesity include type 2 diabetes, hypertension, hypercholesterolemia, heart disease, stroke, gallbladder disease, gastroesophageal reflux disease (GERD), osteoarthritis, sleep apnea, and respiratory problems as well as some cancers (colon, endometrial, breast, lung, esophageal, and kidney). There are numerous other complications and comorbidities that would take pages to list, but would help one better understand the enormity of this disease.
The prevalence of obesity continues to grow in our country and worldwide. It affects everyone in some way but most profoundly affects those with the disease. Interventions are necessary to help control and reverse this epidemic. Supportive environments and collaborative efforts focused on reducing obesity and its comorbidities is essential, as is increasing efforts on prevention through massive public education in order to curb the medical and economic burden of this disease.
Traci Haynes, MSN, RN, BA, CEN, is the director, clinical services at LVM Systems, Inc.
[Look for part 2 of this article in the June/July issue of AnswerStat.]
- Curry, K., Goldsmith, C., & Birn, C. (2015). Adult obesity in the United States: A growing epidemic.
- Gunders, D. (2012). Super-size, super waste: What whopping portions do to the planet.
- Kline, D.A., Goedkoop, S., & Bhimji, S. (2014) Regulation of body weight. com. 27(7), 42-47.
- National League of Cities. (2015). Economic costs of obesity.
- State of Obesity (2016). Fast Facts.
- The Cornell University Food and Brand Lab. (2015).
- Trends in adult body-mass index in 200 countries from 1975 to 2014: A pooled analysis of 1698 population-based measurement studies with 19.2 million participants. The Lancet 387 (10026), 1377-1396.
- Trust for America’s Health. (2004). F as in fat: How obesity policies are failing in America.
- World Health Organization (WHO). (2012). Population-based approaches to childhood obesity. Geneva, Switzerland: Author.
- World Health Organization (WHO). (2015). Obesity and overweight fact sheet.