A Lifetime Condition – Obesity

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Investigated Disease Process

Obesity is a severe global health problem with significant morbidity and mortality across all age groups. This metabolic disorder is a major risk factor for chronic conditions, such as hypertension, cancer, and type 2 diabetes. Obesity screening can detect high-risk individuals that need lifestyle modification, treatment, and education to improve outcomes. It is estimated that 68% of American adults and 33% of children are either overweight or obese (Musich et al., 2016). This paper will describe various components of the obesity disease process, including its pathophysiology, standards of practice, clinical guidelines, disease management, cost impact, and best practices for better outcomes in an organization.

Pathophysiology

Obesity identification and evaluation are critical to effective management and treatment. The disorder is determined based on the BMI, which is expressed as a ratio between an individual’s weight and height. Obesity is clinically defined by a BMI of ≥ 30 kg/m² with a lower cutoff point of 25-29.9 kg/m² being indicative of overweight (Wadden & Bray, 2018). As BMI increases, so does the risk of comorbidity. The condition is further sub-defined into three categories depending on severity: “class I (30.0–34.9 kg/m²), class II (35.0–39.9 kg/m²), and class III (≥40 kg/m²⁾” (Wadden & Bray, 2018, p. 13). However, the sensitivity of BMI as a predictor of body fat may be reduced for bodybuilders and aged individuals. In such cases, x-ray absorptiometry may be used to evaluate adiposity and fat distribution in the body.

Another measure that correlates with adiposity levels is waist circumference, where higher values are associated with a greater obesity-related risk (Ammann et al., 2019). Excess abdominal adiposity compared to total body fat content indicates obesity and related comorbid conditions. Baseline clinical measurements of this variable are a prerequisite for routine weight loss programs. A weight circumference of over 102cm for men and 88cm for women indicates an elevated risk for obesity (Ammann et al., 2019). Thus, high body fat content is a prerequisite for obesity diagnosis.

In most obese patients, the presentation of obesity features complaints about weight or unsuccessful weight loss. In other cases, individuals present with obesity-related complications or comorbidities – such as cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM) – and eating disorders. Therefore, screening for maladaptive feeding habits, including bingeing and limited satiety, for intensive risk factor management is crucial for a sustained weight loss (Wadden & Bray, 2018). Morbid obesity can be identified using the BMI scale.

The etiology of obesity is linked to dysfunctional lipid and glucose metabolism. When energy intake exceeds expenditure, adiposity is elevated, which results in increased inflammatory adipokine production (Leitner et al., 2017). Subsequently, these factors affect the functioning of organs such as the liver and endocrine system, causing comorbid conditions such as CVD, T2DM, and cancer to develop. According to Leitner et al. (2017), inflammatory adipokines may induce insulin resistance, promote thrombosis, or trigger hypertension, which accounts for related comorbidities. However, anti-inflammatory adipocyte agents, including adiponectin, offer effective protection against organ dysfunction or problems such as chronic liver scarring or cirrhosis.

Systemic to cellular changes accompany the onset and progression of obesity. Adipose tissue is useful during a nutritionally deprived condition. However, in times of plenty, excessive storage of fats occurs in the adipocytes, increasing the risk of obesity. It is suggested that keeping lipids in the form of triacylglycerol deposits in these cells prevents the body against lipotoxicity due to free fatty acids (Leitner et al., 2017). However, the development of obesity triggers the lipolysis and subsequent secretion of excess fat molecules, which cause oxidative stress. At the cellular level, the organelles affected include the mitochondria and the endoplasmic reticulum of the adipocytes that form the adipose tissue.

The inflammatory effects of free fatty acids are systemic, exerting oxidative stress to non-adipose organs and increasing the risk for chronic conditions. The adipocytes also suppress lipogenesis, resulting in elevated serum triacylglycerol content, which triggers hyperglycemia and insulin-receptor malfunction (Leitner et al., 2017). Consequently, the hyperglycemic condition created enhances hepatic glucogenesis as a compensatory mechanism. As a result, serum glucose levels increase, causing T2DM.

Besides fat storage, adipocytes also play a role in the endocrine system. Adipocyte-produced hormonal molecules, including adiponectin and visfatin, are used in tissue communication to regulate body-fat levels (Wadden & Bray, 2018). Inflammatory adipokines such as interleukins are transported through the circulatory system to induce inflammation in other organs. The pathophysiologic mechanism for obesity-related comorbidities entails the systemic distribution of adipokines. In severe obesity (class III), accumulated fat deposits in muscles can be as high as visceral levels (Wadden & Bray, 2018). The adipokines released from these organs are transported through the hepatic system, causing inflammation or injury to the pancreas, which affects insulin production.

The inflammatory agents, which are elevated with increasing obesity, trigger conditions such as non-alcoholic steatohepatitis (NASH) and COPD that cause sleep apnea. These components include TNF-α and IL-6 are up-regulated in obesity, and they “induce insulin resistance and perpetuate atherogenesis” (Wadden & Bray, 2018, p. 31). The latter condition progresses from fatty deposits on the endothelium, plaque development, and thrombosis. Factors involved in these processes, including angiotensinogen II, are produced by perivascular white adipocytes and cause vascular lesions and dysfunction, resulting in atherosclerosis (Wadden & Bray, 2018). Thus, inflammatory agents released by adipocytes and free fatty acids are elevated with increasing obesity and contribute to obesity-related comorbidities.

Standard of Practice

The Minnesota recommendations for managing obesity in local primary care settings such as the Minnesota Life Bridge program emphasize effective evaluation, diagnosis, and management of this metabolic disorder in people with developmental disabilities. The assessment of risk levels uses BMI, waist circumference, and the presence of comorbidities (National Heart, Lung, and Blood Institute [NHLBI], 2019).

The BMI estimates body fat based on weight and height and is used to classify disease severity for appropriate intervention. This metric is also utilized in obesity diagnosis. The Centers for Disease Control and Prevention ([CDC] 2019a) has published practices for preventing obesity overweight that combines nutritional interventions and physical activity to improve outcomes. Active lifestyles in multiple environments, including the community settings and schools, can help in weight loss.

Additionally, built environmental designs or approaches that support pedestrian or cycling can also reduce physical inactivity – a risk factor in obesity. The recommendations for children and adolescents (6-17 years) and adults include a 60-minute exercise performed three times a week and a 150-minute intensive aerobic activity weekly, respectively. The CDC (2019a) also proposes reduced caloric intake and increased fruit and vegetable consumption in schools and communities. The framework encompasses early care initiatives for achieving lower BMIs through best practices in diet, infant feeding, exercise, and screen time.

School-based physical activity programs such as CATCH provide opportunities for children to achieve fitness and improve their educational outcomes. Promoting active lifestyles and behaviors in school increases the likelihood of healthier practices in adulthood.

Pharmacologic Treatments

The first-line therapy for obesity is a lifestyle change. However, multiple anti-obesity drugs have been approved by the Federal Drug Administration for use in weight management for obese people (BMI > 30 kg/m²) who remain unresponsive to behavioral therapy, physical activity, and dietary change after a six-month period (Wadden & Bray, 2018). The most common pharmacological treatments in Minnesota include Orlistat, Metformin, Lorcaserin, Phentermine-topiramate, and Bupropion-Naltrexone. The effects of these drugs on individuals in St. Paul Minnepolis metro community with obesity are weight loss, improved lipid profile, and better glycemic control. The standard practice recommendations on drug dosage, indications, and contraindications are strictly followed by the Minnesota Life Bridge program. The only differences are that the intervention includes other medications prescribed for IDD patients and residential care.

Metformin

The mechanism of action of this antihyperglycemic drug involves decreasing the amount of glucose produced by the liver. Metformin has been shown to reduce weight by up to 10% in obese females within six months (Wadden & Bray, 2018). Metformin achieved a 1.1 kg more weight loss than a placebo in hyperglycemic patients. Therefore, the medication is recommended as a first-line drug for obesity patients with T2DM. The most common effect of metformin (850mg twice daily for six months) on this population is improved lipid profile, reduced insulin resistance, and lower blood glucose levels (Wadden & Bray, 2018).

Thus, the drug is associated with significant improvements in patient outcomes. Its side effects include “nausea, diarrhea, and flatulence” (Wadden & Bray, 2018, p. 44). Lactic acidosis may sometimes occur but is uncommon.

Orlistat

Patients who do not respond to metformin are given orlistat. This drug inhibits gastrointestinal lipases, lowering the amount of fats absorbed through the gut. A dosage of 12 mg (three times daily) has been shown to reduce lipid absorption by 30% (Lau & Teoh, 2015). Orlistat also suppresses fat digestion, which lowers the serum levels of free fatty acids. The drug has been approved for obesity treatment at a dosage of 60 mg (three times a day). Orlistat administration was found to have more significant weight loss and maintenance within the first year of therapy than a placebo (10.2% vs. 6.1%) (Lau & Teoh, 2015).

The drug also enhances insulin sensitivity, which leads to lower serum glucose and T2DM risk. Thus, orlistat improved glycemic control, removing the need for insulin treatment in obese people with T2DM. The common side effects of the drug are “oily stool, fecal urgency, increased defecation, and fecal incontinence” (Lau & Teoh, 2015, p. 39). The adverse gastrointestinal events may be prevented through the administration of psyllium with orlistat.

Phentermine-Topiramate

This drug is prescribed to people diagnosed as obese (BMI ≥ 30 kg/m²) or overweight (BMI ≥ 27 kg/m²) and have a related comorbid condition. It acts by increasing norepinephrine levels and effect on the hypothalamus to reduce appetite (Lau & Teoh, 2015). Phentermine is an adrenergic agonist that promotes energy expenditure, while topiramate inhibits taste to lower calorie intake. This combination therapy is given in four doses: an initial 3.75∕ 23 mg, a second dosage of 7.5∕ 46 mg, and a final one of 11.25∕ 69 mg (Lau & Teoh, 2015).

Phentermine-topiramate therapy is recommended for patients with a BMI of more than 36 kg/m² and have comorbid conditions, including T2DM and hypertension. Some of the common side effects of phentermine-topiramate include “dizziness, dry mouth, constipation, dysgeusia, insomnia, and anxiety”, which can be ameliorated through a two-step dosage titration (Lau & Teoh, 2015, p. 35). The first daily dose of 3.75∕23 mg should be administered for two weeks before increasing it to 7.5∕46 mg. The dosage can be raised further to 11.25∕69 mg if the weight loss is less than 3% after the first 12 weeks of therapy (Lau & Teoh, 2015). Gradual discontinuation of the treatment is recommended to avoid inducing seizures. Phentermine-topiramate is contraindicated for patients with heart disease and high blood pressure.

The three medications are effective therapies for weight management in St. Paul Minneapolis metro. They have improved patient outcomes – lower average BMI and better lipid profile – and prevented disease progression to morbid obesity. The hospitalization rates due to obesity-related complications have also dropped because of pharmacotherapy. However, without follow-ups, patient compliance with therapy is low.

Clinical Guidelines

Assessment

The national clinical guidelines for obesity treatment include prescriptive standards for assessment, diagnosis, and patient education. The NHLBI (2019) recommends patient evaluation, BMI and waist circumference be used to assess risk. The patient’s enthusiasm to achieve a lower BMI is an essential component of the assessment. Another important aspect of patient assessment is risk status, which entails evaluating related comorbidities. BMI predicts an individual’s body fat level and is expressed as a ratio between height and weight (Wadden & Bray, 2018). It is utilized to assess obesity and track weight variations over time.

Weight classifications based on BMI fall into underweight (<18.50kg∕m²), normal range (18.50-24.99 kg∕m²), overweight (≥25 kg∕m²) and obese (≥30 kg∕m²) (Ammann et al., 2019). However, BMI cutoff comorbid conditions differ between racial groups. For example, the value indicative of low diabetic and cardiovascular risk ranges between 22 and 25 kg∕m² for Asians (Ammann et al., 2019). Additionally, this guideline does not include expectant women owing to obstetrical risks associated with weight loss during pregnancy.

The guidelines for the evaluation of the risk status entail measuring the obesity level using BMI, abdominal fat (waistline), and occurrence of comorbid conditions. High-risk patients are targets for lifestyle modifications. The approach describes relative risk categories based on the three variables. For example, high-risk values for men and women are a BMI of 30.0-34.9 kg∕m² and a waist circumference of 102cm and 88cm, respectively, plus the presence of T2DM, hypertension, or CVD (Ammann et al., 2019).

A risk-status assessment may reveal severe conditions or organ injury, requiring more aggressive lifestyle modification. The presence of myocardial infarction, sleep apnea, angina pectoris, and atherosclerotic disorders indicate an elevated absolute risk. Other factors to consider during the assessment include physical inactivity – may trigger CVD and T2DM – and high triglycerides (>1,000 mg∕dL), which could cause acute pancreatitis. The evaluation of patient incentive or readiness to lose weight is also critical. The individual should be committed to the goals of the program for better outcomes.

Diagnosis

The national guidelines for obesity diagnosis use BMI. A BMI of 25.0-29.9 kg∕m² is defined as overweight, while higher values (30.0-34.9 kg∕m²) suggest obesity (Wadden & Bray, 2018). Severe obesity is diagnosed when the computed BMI exceeds 40 kg∕m². Based on these criteria, patients can be classified into obese I (30.0-34.9 kg∕m²), II (35-39.9 kg∕m²), or III (≥40 kg∕m²) for treatment and intervention.

Patient Education

The objective of educating obese or overweight people and at-risk groups is to reduce weight, sustain it, and avoid relapse in unmotivated individuals. The standards for this segment of obesity treatment encompass measures to lower BMI and maintain it as well as control related risk factors (Wadden & Bray, 2018). A weight loss plan should be developed for an obese patient who has demonstrated a willingness to achieve a normal BMI range. The therapy program entails education and counselling of the individual on weekly weight targets through appropriate dietary and exercise prescriptions (Lau & Teoh, 2015).

It also includes the identification and mitigation of potential risk factors and regular evaluation to determine progress. Sustaining the goals achieved and preventing further weight gains require dietary interventions, behavioral modifications, and intensive physical activity (Lau & Teoh, 2015). Those exhibiting symptoms of binge eating disorder can receive cognitive behavioral therapy to treat this condition.

Standard of Practice Disease Management

The procedures and recommendations for managing obesity in my community – St. Paul Minnepolis metro area, Minnesota – are largely similar to the clinical guidelines recommended by the CDC. The focal areas are the management of obesity and related comorbidities using pharmacological and nonpharmacological interventions and monitoring weight-loss progress. Consistent with the national guidelines, the intellectual and development disabled (IDD) people – the patients I work with – diagnosed with obesity receive dietary recommendations, exercise program, and behavioral therapy to achieve a lower BMI.

Additionally, weight loss medications are used as adjuncts to lifestyle modification to moderate caloric intake and enhance physical activity. Other standards of practice, according to the clinical guidelines, implemented in this program include diagnosis of obesity based on BMI cut points and patient education. Routine follow-up for overweight IDD patients helps monitor weight loss and drug side effects and promote adherence.

A major difference between the standard of practice adopted for obese IDD patients and national guidelines relates to the provision of short-term intensive care. An out-of-home service of up to 180 days is provided to IDD individuals in a behavioral or medical crisis (Krueger & Reither, 2015). Supported living is also offered to persons with disabilities and includes healthy food, personal grooming, and social support to address social stigma and build the self-esteem of obesity patients. Assessment and diagnosis are the same regardless of the intervention type. However, nonpharmacological management does not involve drug therapy or bariatric surgery but lifestyle modification – dietary change and physical activity.

Managed Disease Characteristics and Resources

Effective obesity management is critical to avoiding associated comorbid conditions. Patients must adopt lifestyle modifications to achieve weight loss targets and maintain them. Specifically, adherence to the recommended dietary regimens, physical activities, and behavioral change can help in controlling BMI (Lau & Teoh, 2015). Thus, self-monitoring of energy intake and expenditure and engagement in moderate-to-intensive exercise routine are key characteristics of a patient with well-managed obesity. Additionally, the individual maintains a healthy BMI range of 18.5-24.9 kg/m² by leading a healthy lifestyle. Therefore, health literacy is important in well-managed disease.

Resources for a well-managed patient with obesity, including pharmacological and nonpharmacological treatments, should be made available to the patient. Access to evidence-based drugs and weight-loss surgical care can help individuals manage their conditions effectively. Additionally, evaluation and management of other comorbid conditions such as T2DM and coverage can increase the quality of life of the patient. The available treatment options include nonpharmacological care (diet and physical activity), drugs such as orlistat, behavioral therapy, and bariatric surgery.

A well-managed patient leads a better quality of life than the one with unmanaged obesity. Obesity is associated with a low life expectancy compared to other chronic diseases (Lau & Teoh, 2015). However, a well-managed disease is associated with a significant improvement in the quantity of life. Maintaining a healthy BMI and treating life-threatening comorbidities ensure positive health outcomes. As a result, the patient is protected from mortality risk factors and can lead a longer, healthier life.

International and National Disparities

Obesity management and prevalence vary between different socioeconomic groups, races∕ethnicities, regions, or states. Among the contributing factors include access to care, payor source, available treatments, and level of education. In the US, wide racial disparities exist in obesity prevalence. Aggregated data in the 2015-2017 period show that adult obesity∕overweight rate is higher in African Americans (38.4%) than in whites (28.6%) (Petersen, Pan, & Blanck, 2019).

One cause of this disparities is differences in access to care due to socioeconomic disadvantages experienced by ethnic minorities. Underlying factors that account for the high obesity rates in African Americans include lower education rates, unemployment, limited availability of healthier food options, a lack of physical activity facilities, and inadequate self-care resources (Petersen et al., 2019). Obesity-related complications increase the medical spending of patients. Minority populations, who constitute the majority of the uninsured (lack access to private insurance or Medicare∕Medicaid cover) use out-of-pocket spending. They are also less likely to receive prescription medications provided to Medicare beneficiaries or afford costly procedures such as bariatric surgery.

To address these disparities, the CDC has developed healthy nutritional standards that are aligned with clinical guidelines for schools, manufacturers, and other agencies at the state and local level. The goal is to ensure that at-risk groups access healthier food. Another intervention aligned with the clinical guidelines for increasing physical activity includes transportation systems that promote exercise. They include public sidewalks and parks in places occupied by at-risk minority groups.

Wide disparities in obesity rates occur internationally. In China, increasing incomes have led to better nutrition and living standards. However, on average, the BMI of the Chinese people has grown over the past few decades, with over a quarter of urban children being obese due to dietary changes (Krueger & Reither, 2015). Nutritional and socioeconomic inequalities account for disparities in obesity rates between provinces.

A review of the Chinese standards for the management of obesity∕overweight shows that the treatment approaches are largely similar to those adopted in the US. They include increasing obesity awareness, mass-participation sports activities and exercises in workplaces, the number of nutritionists nationally, and healthy eating in school – Eat Smart at School (Krueger & Reither, 2015). In contrast, the UK promotes pharmaceutical agents (Orlistat) in addition to lifestyle changes to treat obesity. These interventions parallel the management strategies used in the US – diet, physical activity, behavioral modification, and pharmacotherapy.

Access to care has been increased in China by training more healthcare workers. The country’s National Institute of Nutrition and Food Hygiene reports that the number of nutritionists stands at over 11,000 and efforts are being made to achieve the internationally recommended standards of one provider per 300 people (Morgan, 2014). Healthier lunches have been made available to schools to promote healthy eating habits. The payor source for obesity patients includes a publicly financed health insurance that includes tailored products for urban and rural residents. The treatment received include conventional pharmacotherapy, surgical care, and traditional Chinese medicine, “acupoint catgut embedding” (Morgan, 2014, p. 1039). Components of western medicine, such as dietary regulation, exercise, and behavioral modification have also been integrated into obesity management in China.

The Chinese and UK patient care approaches are largely aligned with the US clinical guidelines for the treatment of obesity. Both China and the US have adopted dietary change (nutritional recommendations for school lunches), behavioral therapy, physical activity, and surgical care to treat this condition. Similarly, the UK’s Health, Exercise, and Nutrition in the Really Young (HENRY) intervention seeks to promote healthy eating, exercise, and emotional support of children. Another similarity lies in increasing access to care through training more nutritionists and providing coverage to rural or disadvantaged groups. However, while the US and the UK has adopted formal legislation to guide television advertising of processed food and labeling, such a law is yet to be implemented in China. Another difference is the use of traditional medicine in addition to conventional medicine by the Chinese in obesity treatment.

Managed Disease Factors

The management of obesity entails medical care, including counseling, consumption of low-calorie food, exercise, and pharmacotherapy. Therefore, access to care is a critical factor in achieving a well-managed disease. Weight loss and maintenance rely on the accessibility of medical care or community hospitals and programs that address the risk factors. Additionally, access to FDA-approved drugs to treat obesity or bariatric surgery is required for better outcomes. A second critical factor in a well-managed disease is a payor source. An insured∕uninsured status affects the amount of medical services – counseling and pharmacological agents – that available to the patient.

Some states offer comprehensive obesity care to Medicare∕Medicaid beneficiaries, while others do not provide any coverage for this population (Carra & Schulz, 2018). Therefore, obese residents of areas that offer full coverage will have a well-managed condition. Health literacy is an important factor in adherence to treatment to achieve a lower BMI that is associated with a well-managed disease (Carra & Schulz, 2018). People with a greater awareness of self-management dietary regimen and physical activities are less likely to be overweight or obese.

Unmanaged Disease Factors

The factors identified above – access to care, payor source, and health literacy – can negatively affect a patient’s ability to manage his or her obesity. A lack of medical centers or providers will mean that obese people within the community will not be enrolled in weight management programs, counseling, drugs, or bariatric surgery. As a result, they will struggle with a poorly managed disease. The health insurance available varies across regions and account for socioeconomic disparities in obesity rates (Carra & Schulz, 2018). Thus, an economically disadvantaged obese person residing in states that offer limited Medicare∕Medicaid coverage will exhibit a poorly managed disease. On the other hand, low health literacy levels will limit health-seeking behavior and adherence to treatment, affecting weight loss management and maintenance.

Unmanaged Disease Characteristics

Patients with unmanaged obesity are characterized by a BMI that exceeds 24.9 kg/m². Fundamental behaviors predict the severity of obesity and related comorbidities (Krueger & Reither, 2015). Patients with unmanaged obesity present with medical complications such as T2DM, hypertension, and CVD. They exhibit a low adherence to dietary recommendations and physical activity levels essential in managing their BMI. Additionally, they do not regulate their caloric (sugar and salter) intake or engage in workout routines associated with a healthy lifestyle. Such patients may also frequently engage in binge eating. Their literacy level is also lower than that of individuals with well-managed obesity.

Patients, Families, and Community

I serve in the State Group Homes that targets the Intellectual and Development Disabled (IDD) under a program called Minnesota Life Bridge. The increasing number of obese adults (current prevalence stands at 24%) is a major concern in St. Paul Minnepolis metro area, Minnesota (CDC, 2019b). The Minnesota Life Bridge provides crisis respite services to IDD individuals, such as assessment, consultation, coverage, and transition care to resolve behavioral or medical issues. The interventions also include obesity management for this population. This condition has had significant direct effects on patients and indirect economic impacts on families and the entire community.

Burden to Patient

Obesity is associated with a high incidence of chronic conditions such as T2DM, high blood pressure, coronary heart disease (CHD), stroke, and cancer, which are risk factors for increased hospitalizations.

Therefore, the direct effects of obesity on the patient include increased medical burden, morbidity, and all-cause mortality. The social and emotional consequences of this condition – stigma and depression – result in poor mental health outcomes and lower the quality of life of obese adults. Techakehakij (2016) found that quality-adjusted life-years (QALYs) lost due to childhood obesity in Thai adolescents is about 0.04 at 3 years and 0.59 at age 18. Obese people also experience limitations in performing activities of daily living, including grooming, and discriminatory wage effects. Physiologically, they are at risk of shortness of breath and obstructive sleep apnea that reduces their quality of life.

Burden to Family

Informal caregivers, unlike trained ones, are vulnerable to physiological and emotional effects of caring for people with morbid obesity. Additionally, the high medical spending on chronic conditions can be a significant financial burden on the family. The intense and multifactorial nature of the disease causes a strain on relatives who have to balance competing priorities. They have to ensure that the home environment supports healthier eating and fitness practices and behavioral changes to achieve sustainable weight loss. Providing assistance with activities of daily living, promote a positive self-image, and participate in education and counseling with their obese relative is also critical.

Burden to Community

The indirect effects of obesity on the society or nation is productivity loss due to increased rate of absenteeism of patients and caregivers. The costs of treating related comorbidities are also high. In the US, healthcare spending on obesity and associated disorders increased by 29% between 2001 and 2015 (Tremmel, Gerdtham, Nilsson, & Saha, 2017). Obesity is also linked to lower productivity because of social stigma, longer and frequent sick leaves, disability pension due to debilitating illnesses, and premature death, which increase indirect costs to employers.

Costs

Patient Costs

The direct healthcare expenses on the obesity patient arise from outpatient and inpatient care due to an increased risk of comorbidity. Drug and hospital spending due to obesity-related chronic conditions are the main driver of the high costs. The treatment of stroke, T2DM, hypertension, and CHD increases medical expenditure by $9,000-17,000 in obese patients compared to normal-BMI individuals (Meldrum, Morris, & Gambone, 2017). Direct costs may come from surgical care, lab and radiological tests, medications, and physician services.

Family Costs

The direct economic impact of obesity on family members is high. They incur monetary costs related to spending on drugs, lab tests, physician care, and weight loss programs or interventions. Further, significant family resources may go into sports/physical activity purchases and switching to healthier diets, which may impede dietary modification. Healthy menus provided by groceries may be expensive than food sold by budget outlets. Other direct cost components are payments for interventions, travel expenses associated with taking the patient to and from weight loss programs, and alternative care (paid caregivers) (Meldrum et al., 2017).

Thus, the financial burden shouldered by the family is significant. An indirect cost includes time spent helping the individual through lifestyle interventions. One has to adjust his or her working pattern or negotiate flexible work shifts to attend such programs. Some may even quit employment to care for their obese family member, resulting in lost income, which may lead to social/emotional problems, poor relationships, and tensions.

Community Costs

BMI increases have implications for security, economic productivity, and healthcare expenditure. Obese people, owing to their lower fitness levels, may not be enlisted into the military or law enforcement. Additionally, they are perceived as high-risk employees and employers may charge higher insurance premiums or give more payouts for these individuals than for non-obese staff (Meldrum et al., 2017). Thus, additional costs may affect the profitability of companies.

As a result, employers offer lower wages to this population, resulting in reduced household income and poverty. The value of lost work also directly affects the community. Prolonged sickness absence by obese workers due to chronic illness, long-term disability, or mortality impacts the labor market outcomes. Reduced productivity may also come from suboptimal performance in the workplace. Time off work to provide care to an obese family member may lead to lower output.

Best Practices

Mounting effective, evidence-based interventions can help reduce obesity rates nationally. No significant deviations in interventions used to tackle this epidemic in Minneapolis from the best practices were found. They include nutritional improvement, physical activity interventions, and social support. Among the anticipated patient outcomes of these three initiatives are decreased calorie intake, weight loss and maintenance, and reduced social stigma. However, I would like to see improvements in the dietary program, such as conducting healthy food festivals and providing nutritious school lunches to the at-risk subpopulation – IDD patients.

Nutritional improvement may also be achieved by adopting zoning to restrict fast-food joints from residential areas, as increasing accessibility to groceries has been linked with higher fruit and vegetable consumption (Otterbach et al., 2018). Promoting community gardens is another population-level approach to improving dietary behaviors. At the organizational level, cafeterias and eateries in learning institutions and workplaces should be compelled to include caloric content of items on their menus, provide more fruits/vegetables, and reduce sugar-sweetened drinks (Otterbach et al., 2018). Such actions would reduce factors predisposing people to higher calorie intake. Increased awareness through nutritional education is required to realize this goal.

Physical activity interventions can contribute to a lower mean BMI in this community. Environmental changes to provide safe routes for moderate-to-intense exercises will be consistent with the national guidelines. Establishment of more parks, cycling paths, and walking spaces around St. Paul Minneapolis metro area will support physical activity. Reducing screen time exposure can reduce childhood/adolescent weight gain. According to Robinson et al. (2017), increased media viewing exposes children and adolescents to high-calorie products and drinks through ads, influencing individual preferences and eating patterns. Thus, reducing sedentary activities will decrease weight gain in these subpopulations and lower the risk of obesity.

Social support initiatives can help improve self-image and prevent relapse to unhealthy behaviors. The rationale for selecting nutritional improvement and physical activity is to balance energy intake with expenditure, resulting in normal-range BMI. Social support can reinforce positive dietary behaviors and adherence to physical activity routines.

Plan Implementation

A proposed intervention for nutritional improvement to reduce obesity in St. Paul Minneapolis metro area is initiating a fresh fruit/vegetable program for schools and other learning institutions. The goal is to ensure children and adolescents meet the daily dietary recommendations and reduce calorie intake through media promotions, newsletters, and cooking demonstrations. Parental involvement in this initiative will support a transfer of healthy eating behaviors to homes, as schools alone cannot tackle the obesity problem (Fitzpatrick et al., 2016). The program will strengthen the collaboration among parents, educators, and nutritionists to share practices and role-modelling of healthier eating behaviors.

An intervention to promote physical activity will entail an exercise package that includes social incentives and delivered through an online for a wider reach. Families will engage in a moderate-to-intense 60-minute workout, which is recommended for improved metabolic health (Fang et al., 2019). Participants enrolled in the program will form a chat group on social media with a trainer who will supervise the physical activity routine, monitor their improvement daily, and give health advice. Members will receive praise for reaching the recommended workout levels. However, those who fail to meet them will not be ridiculed or criticized. The trainer will remind the members to finish the exercise assigned and address any barriers or challenges they may experience.

A supportive environment to sustain weight loss and behavior change will be achieved through social media networks. The emotional support, information, and encouragement delivered through such online platforms have been shown to improve the outcomes of dietary and weight loss programs (Jane, Hagger, Foster, Ho, & Pal, 2018). Thus, through social connectedness among obese people and increased interaction with a trained professional through podcasts or apps, the target population will be able to achieve a lower BMI. Information sharing between the members of the public will also lead them to try dietary changes on their own.

Plan Evaluation

The quantity and frequency of fruit and vegetable (F&V) intake will be measured and compared to the recommended amounts to assess the success of the first intervention. The post-intervention values obtained through a random household survey should be equivalent to the daily dietary recommendations of five servings of F&V (Jane et al., 2018). The program should translate to increased F&V consumption from the baseline.

The second intervention (a 60-minute online exercise package) will be measured through pre-/post-program surveys. Actigraph accelerometers worn on the wrist will be used to provide objective assessments of the daily physical activity levels of the participants during workouts (Fang et al., 2019). Additionally, the pre-/post-intervention anthropometric values – height and weight – will be measured to compute BMI changes as a result of the program.

An objective measure of the impact of supportive social media on weight management will be a self-reported survey tool on behavior change. Pre-test and post-test results will be analyzed to determine the effectiveness of the initiative (Jane et al., 2018). The number of visitors to the site, comments, and supportive videos posted will also indicate the efficacy of the program.

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