The Obesity Epidemic and How the Emergency Physician Can Help

Author: Jennifer Robertson, MD, MSEd, NBHWC (EM Attending Physician/Assistant Professor, Emory University School of Medicine) // Reviewed by: Summer Chavez, DO, MPH, MPM (EM Attending Physician, The University of Texas Health Science Center at Houston); Alex Koyfman, MD (@EMHighAK); Brit Long, MD (@long_brit)

Case:

A 50-year-old female with a past medical history of type 2 diabetes, breast cancer (in remission), and hypertension presents to the emergency department (ED) for chest pain for the last 2 days. She has normal vital signs and normal electrocardiogram, and you have a low clinical suspicion for acute coronary syndrome. Her high sensitivity troponin is negative. You decide to discharge but wonder what type of follow up she needs. You know she needs referral back to her primary care doctor and perhaps cardiology. The problem? She is unable to get in to see her primary care doctor for at least six months. She also has a body mass index (BMI) of 42, which places her in the class III obesity category. You wonder what you could do to help in the meantime…


Introduction

Obesity is a disease process that is rampant in the United States (1). Overall, from 1999-2000 through 2017-2018, the prevalence of both obesity and severe obesity increased among adults in the United States. According to NHANES (National Health and Nutrition Examination Survey) data, the age adjusted prevalence of obesity in adults was 42.4% without any significant differences between men and women or by age. Severe obesity prevalence in adults was found to be 9.2%, higher in women than men (1). Obesity also is a significant cost to the healthcare system (2) and has been associated with higher numbers of ED visits, delayed ED care, and higher costs in some circumstances (3,4).

Obesity is a complicated disease process that may lead to abnormal physical forces, as well as abnormal endocrine and immune function (5). Body fat may cause a mechanical load and stress on body tissues. This can lead to disease processes such as hypertension from surrounding renal fat, osteoarthritis from weight on the joints, gastrointestinal reflux disease (GERD), tissue friction (intertrigo), and others (5).  Excess fat may also produce “sick fat disease”, also known as “adiposopathy”, when multiple pathogenic adipocyte and/or adipose tissue endocrine and immune dysfunctions contribute to metabolic disease (5). Over the years, research has demonstrated that body fat has many metabolic, immunologic, and hormonal functions in addition to energy storage (6, 7). Adipose tissue produces multiple adipokines that are important for physiologic processes such as appetite, satiety, insulin secretion and sensitivity, endothelial function, inflammation and others (6). While there are some adipokines that may be helpful, such as adiponectin as an insulin sensitizer and anti-inflammatory, it is thought that many adipokines that are elevated in obesity may contribute to the inflammation and metabolic abnormalities that one may see (6).  Associated diseases due to inflammation and metabolic abnormalities from excess fat mass include type 2 diabetes mellitus (T2DM), cardiovascular disease (CVD), obstructive sleep apnea (OSA), depression, cancers, liver diseases, and others (6, 8).

Finally, it should be noted that obesity, per se, is not the cause of all disease as there are individual variations (9). How an individual handles excess energy balance is key. Rather than total fat mass, it is thought that that body fat distribution and an impaired adipose tissue function better predict related complications at the individual levels (9). For example, visceral, abdominal and upper body fat tend to be worse than lower body superficial fat (9, 10). However, the more “benign” subcutaneous fat can hypertrophy enough that ectopic fat deposition occurs in other regions such as the liver, heart and vessels. It is thought that this ectopic fat that may increase metabolic and cardiovascular risk (10).


Umm… why the emergency department?

Obesity is associated with many conditions that underlie common emergencies in the ED, including diabetes (diabetic ketoacidosis), hypertension (hypertensive emergencies), obesity hypoventilation (respiratory failure), cardiovascular disease and others (5, 8). In addition, obesity can directly cause complications and difficulties in the ED. Obesity is associated with difficult IV access, difficulty accessing procedural landmarks, difficulty with radiology reads, difficult airways, and even additional trauma complications and higher mortality from trauma (11-14). Patients may also present to the ED due to complications from bariatric surgery, including peritonitis, fistulas, hernias, gastric erosion, dumping syndrome, and others (15).

While emergency physicians may be aware of the more acute risks of obesity, there is probably less attention paid to the etiology or reasons behind a patient’s obesity. Rather, we tend to evaluate and treat the conditions associated with obesity first rather than addressing the underlying cause. Of course, as emergency providers we always need to tend to the emergency first. However, we may, as frontline caregivers, make a positive difference in a patients’ lives by helping them get a jumpstart on weight loss and overall lifestyle changes (16).

As of the current publication date, no papers could be located on studying prevention of obesity in adults from the ED setting. However, there have been a few limited studies on obesity evaluation and interventions in pediatric emergency departments (16-18).  In a 2015 study of African-American and Latino children (mean BMI 25.6) in a pediatric emergency department, Haber and colleagues evaluated whether the children and their parents benefited from an educational intervention regarding diet and exercise. Out of 100 children aged 8-18 years of age, 81% of African-American children and 96.1% of Latino children stated learning new information from the intervention program. In addition, 85.7% of African-American parents and 97.3% of Latino parents planned to make changes in their childrens’ diet and exercise regimens (16). Overall, the authors concluded that the ED may be a good place to provide education regarding lifestyle, including diet and exercise (16). Another similar study evaluated the prevalence of obesity in a sample of children visiting a pediatric emergency department and whether their parents were receptive to intervention in the ED. Overall, the authors found a high prevalence of overweight and obesity (36.7%) and also found that over one half of African-American parents and 32% white parents were receptive to an overweight/obesity intervention from the ED (18).

Despite the limited research, especially in adults, the ED it may be a perfect place to start the intervention process. This could include simple education and referral for nutrition, physical activity and weight loss advice.


Why can’t my patient just eat less?

Obesity is a disease of excess energy storage (5). However, maintaining body weight is much more complicated than simply eating less and exercising more. This is because there are opposing forces in the body that defend higher body weight after lifestyle (not surgically) induced weight loss. For example, in the Biggest Loser, most regain some (if not all or more) of their pre-show body weight (19). There are many reasons behind this, but a few ways the body may do this after weight loss is by lowering basal energy expenditure, lowering leptin and raising ghrelin levels (20). Other forces that may work against patients with obesity are medications that promote weight gain, including beta blockers, insulin, sulfonylureas, TZD and antipsychotics (5). Besides these forces, there are other contributors to the obesity epidemic, including the Western diet which consists of high fat, high sugar, and highly processed foods (21, 22). In addition to being more energy dense, highly processed foods may be more efficiently processed in the gastrointestinal system, leading to an increased absorption of macronutrients. They may also possibly adversely affect the gut microbiome (21). In addition, it is also hypothesized that circadian disruption, food insecurity (23), lack of physical activity and potentially even the microbiome may contribute to weight gain (5). Many patients with obesity actually may not eat much at all and yet, still struggle with weight (24, 25).

Some suggestions to start the conversation (5):

1. Ask permission

2. Use “people first” language

3. Consider biases

4. Provide basic nutrition information

5. Consider food insecurity

6. Provide resources for physical activities

7. Provide referrals to appropriate specialists


Ask Permission

One should always ask patient’s permission to discuss their weight (5). Many patients with obesity likely know they need to lose weight and many may already be trying. However, others may simply be not aware that their weight and lifestyles are causing potential or real harm. Therefore, asking permission is always prudent. Some may really want advice or assistance and others may not. Therefore, asking permission is always prudent. Consider a phrase such as, “I see you have had trouble with your blood sugars lately. Would it be okay if we discussed some ways to improve your blood sugar without medication, such as diet, physical activity and weight?” For patients who decline to discuss this further, then your job is done.


Use People First Language

If patients are agreeable to discussing their weight, consider using “people-first” language (5). Essentially, people first language helps avoid the risk of labeling a person by his or her disease. For example, “patient with obesity” is preferred over “obese patient”. This is the same for patients with obesity. In addition, the Obesity Medicine Association encourages terms such as “weight”, “body mass index”, “excessive energy stores” or “affected by obesity” (5). Discouraged terms include “morbidly obese” and “fat”. Rather, for patients with high body mass indices (BMI), consider using the terms “class I, class II or class III obesity” (5). As a reminder, here are the definitions for the classes of obesity as well as their risk for developing associated diseases (AAE).

Underweight < 18.5 –– low disease risk but mortality may be higher due to other causes (smoking, suicides, other external factors) (26).

18.5-24.9: normal – average disease risk
25-29.9: overweight – increased disease risk
30-34.9 obese class I – moderately increased disease risk
35-39.9 obese class II – severely increased disease risk
≥ 40 obese class III – very severely increased disease risk


Consider Biases

Consider weight bias as well. Some patients with obesity may have had others, including healthcare providers, inadvertently provide suggestions or perhaps have had biases that negatively impact patients. Unfortunately, weight bias exists not in the general population but in healthcare as well (27-30). Unfortunately, when patients experience weight bias, they are less likely to follow up and follow through, avoid screenings, cancel appointments, and demonstrate poorer outcomes with treatment (28, 30).  Therefore, being supportive, even starting in the ED, may help that patient get a good “jumpstart” to improving patient health and well-being.


Provide Basic Nutrition Information

As physicians, many of us have not received a lot of training in nutrition. For weight loss, research has demonstrated that the macronutrient content of one’s diet is less important than reduced total calorie intake (31, 32). In a 2009 randomized controlled trial of 811 adults randomized to four calorie reduced diets, all led to weight loss and the actual macronutrient content mattered less. The authors found that engagement in care including group session attendance was also very important in determining weight loss (31). In a 2014 JAMA study of various low carbohydrate versus low fat versus moderate macronutrient diets, the overall weight loss (versus no diet) was statistically non-significant between each group. Authors concluded that any diet, given hypocaloric, should work in the long term if there is adherence (32).

Some patients with obesity are actually malnourished and may have vitamin deficiencies (33-36). This may be due to consumption of highly processed foods low in micronutrients (35). In addition, bariatric surgery predisposes to malabsorption of vitamins and minerals and even excess adiposity itself may predispose to vitamin D deficiency (37). Hopefully, patients who have had bariatric surgery have received diet advice from their physicians but if not, then certainly referrals back to their physicians would be recommended (5). While hypocaloric diets may be recommended for weight loss, overall nutrient richness is still important. The Mediterranean diet is highly recommended for overall health as it is rich in micronutrients and phytochemicals. Finally, if one is really looking for a specific diet that has the best evidence, then fixed-calorie meal replacements may be the way to go (38, 39).


Consider Food Insecurity

Food insecurity is essentially defined as the inability to maintain consistent access to nutritious foods (40). In the United States (US), approximately one in seven households experience food insecurity at times during the year (40). Studies have shown some relationship between food insecurity and obesity (23, 40). In one study of US adults in 12 states, patients with food insecurity had 32% increased odds of being obese compared to food secure adults (23).  While some studies have been mixed, food insecurity has been more consistently shown to be associated with obesity in women and in female headed households (40).  Unfortunately, high fat and high sugar foods tend to be less expensive and thus, this may be a contributor toward the relationship (Franklin). However, this may not contribute entirely to the relationship between food insecurity and obesity, especially in women.  Factors such as body composition differences between men and women may also be a factor (40).

Food insecurity is also associated with increased ED use as well as hospitalizations (41). Screening for food insecurity may be a challenge for physicians (42), however, it can be assessed using a two-item screen, which asks patients if each of the following statements are often true, sometimes true or never true for his or her household in the previous 12 months (1) “We worried whether our food would run out before we got money to buy more” and (2) “The food that we bought did not last and we did not have money to get more” (43). Often or sometimes true responses to either statement indicates a positive screen (43). Patients with a positive screen may be a challenge, however linking to community resources may be key (44). This includes support for enrolling in federal nutrition assistance programs such as SNAP (Supplemental Nutrition Assistance Program) and WIC (Special Supplemental Nutrition Program for Women, Infants and Children) (44). Other possibilities include collaborating with local food banks, community-based food pharmacies that fill prescriptions for tailored food for children with chronic diseases, and vouchers for reduced- or no-cost produce that are redeemable at local food vendors (44). Finally, if patients dial 2-1-1, food banks and other resources for basic human needs can be reached (44).


Referrals for Physical Activity

Physical activity is important for all and may improve several metabolic and health parameters in patients with obesity (5). Physical activity assists with weight loss and maintenance, improves body composition, improves adiposopathic psychologic disturbances, and improves insulin sensitivity (5). It also helps improve metabolic, musculoskeletal, cardiovascular, pulmonary, mental, sexual and cognitive health (5).  Unfortunately, only about one in three adults presenting to a physician or other health professional have received any advice regarding the importance of physical activity (45). This is certainly an area that needs improvement, and any physician can step in to help.

Simply encouraging patients to be more active can be done by emphasizing the basic messages of current PA guidelines: “more activity is better than none” and “more is better than less, at least up to a point (46) can be helpful.  For substantial health benefits, adults should do 150-300 minutes a week of moderate intensity or 75-150 minutes of vigorous intensity aerobic physical activity per week.  In addition, adults should do muscle-strengthening activities of moderate or greater intensity involving all major muscle groups on two or more days per week (47).

For those living in unsafe and/or very hot or very cold environments, walking at the shopping mall or local recreation center may be helpful. If one feels uncomfortable providing suggestions, then simply referrals to exercise specialists and promotion of physical activity can be beneficial for patients in terms of changing physical activity habits (48, 49). Finally, it should be mentioned that higher risk patients, such as those who are very inactive and have disease and/or those with advanced cardiovascular, renal or metabolic disease may need full medical clearance prior to starting any activity program. Thus, referral back to specialists required for medical clearance may be necessary for some (5,50).


Referrals to Specialists

Along with initial suggestions for patients, referral to primary care, an obesity medicine physician, a nutritionist, and/or other obesity medicine specialists is also important. Simply telling someone to exercise and eat right likely will not likely work, and patients likely may need multiple professionals in their court, including nutritionists, physicians, athletic trainers, health coaches, bariatric surgeons, mental health professionals and others (5).


Conclusions

  • Obesity is considered a chronic, progressive disease resulting in adverse metabolic, biomechanical and psychosocial health consequences (5).
  • Obesity itself not an emergency, but its consequences can be.
  • Given the many patients who utilize the ED as a place for their primary health care, it may be a good time to take an extra minute or two to provide a few tips and referrals.
  • Consider referrals for nutrition and physical activity.
  • You may make a significant difference in patient’s life for the long term.

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