1. Clancy, Carolyn M. MD

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NEW FEDERAL DATA about obesity's prevalence in the US population confirm what nurses, physicians, and other health care professionals know too well. Obesity rates are escalating among millions of children and adults, bringing higher risk for serious, long-term health conditions.


Today, 72 million Americans are considered to be obese or have a body mass index at or more than 30. Data released in August 2010 by the Centers for Disease Control and Prevention underscored the evolution of this decade-long trend.1 In 2009, 9 states reported that obesity was prevalent or affecting 30% or more of the population. In 2000, no state reported that prevalence.


High rates of obesity occur in states that already struggle with significant chronic disease burdens: Missouri, Oklahoma, Arkansas, Louisiana, Mississippi, Alabama, Tennessee, Kentucky, and West Virginia. Only Colorado and Washington, District of Columbia reported obesity prevalence of less than 20%.



While the Centers for Disease Control and Prevention data revealed the extent of the obesity epidemic, recent reports from the Agency for Healthcare Research and Quality (AHRQ) offered additional insight about why some populations may be especially affected. Even as rates of obesity surged in the past decade, fewer adults were told by a health care professional that their weight classified them as obese or overweight, according to data from AHRQ's 2009 National Healthcare Quality Report (NHQR).2 Produced by AHRQ for the seventh consecutive year, the report measures trends in effectiveness and timeliness of care, patient safety, efficacy, and patient-centeredness.


Between 1999 and 2002, more than two-thirds (67.8%) of adults older than 20 years said that they were informed by a health care professional of their unhealthy weight condition. By the 2003-2006 reporting period, however, this percentage dropped to 64.8%. In both time periods, obese adults aged 20 to 44 years-a period of time when healthy behaviors may be easier to develop-were less likely than those between the ages of 45 and 64 years to be told by a health care professional that they were overweight.


It is reasonable to assume that overweight or obese individuals already are aware of their weight condition and might not welcome a reminder from their nurse or physician. However, research indicates that exercise advice from a health care professional can be an effective weight-loss intervention, according to the US Preventive Services Task Force, an independent panel of experts on primary and preventive care.3 Furthermore, this advice has been shown to yield higher levels of activity among sedentary patients.4


Despite its potential benefits, the frequency of professional advice about exercise among all population groups remained essentially unchanged between 2002 and 2006, according to the NHQR. Uninsured adults younger than 65 years fared the worst. Only about a third (36%) of uninsured individuals received that advice in 2004, although that percentage increased to 41% in 2006.


Among adults 65 years and older, the NHQR found that individuals with public insurance alone (Medicare and Medicaid) were less likely to receive advice about exercise than those with Medicare and supplemental insurance. In 2006, 58% of adults older than 65 years with public insurance alone had received advice about exercise, down from the peak of nearly 65% in 2004. In contrast, 68% of individuals with Medicare and private insurance received that advice in 2006, a slight reduction from the peak of 70% in 2004.



Disparities, or gaps in care experienced by one population group compared with another, were also evident in access to advice about obesity, according to the 2009 NHDR.5 An annual companion to the Quality Report, the NHDR uses the same overall measures as the quality report, and it identifies where disparities in care lie and how they change over time. Previous reports have shown that major disparities exist for blacks, Hispanics, poor, and uninsured individuals in many areas of health care. Unfortunately, that trend persists in access to counseling about obesity, according to the 2009 NHDR.


Obese adults who are black or Hispanic or have less than a high school education are less likely to receive advice about good food choices from their doctors, according to a new section on lifestyle modification. While more than half (53.6%) of obese whites received advice about eating less high-fat or high-cholesterol foods, only 44.9% of blacks and 42.2% of Hispanics did so. A similar trend prevailed in access to advice from a health care professional about exercise. Sixty-one percent of whites received such advice, compared with 56.7% of blacks and 48.5% of Hispanics.



Our work is clearly cut out for us if we hope to minimize the impact of these dangerous trends. The new Patient Protect and Affordable Care Act, signed into law by President Obama on March 23, 2010 contains provisions that make obesity counseling easier to obtain.6 Beginning in January 2011, patients covered by Medicare will get additional preventive services, such as an annual wellness visit and nutrition counseling for people at risk for chronic diseases such as diabetes. These are among the preventive services and screenings with an "A" or a "B" recommendation from the US Preventive Services Task Force.


Medicare patients now pay 20% of the cost of most preventive services. As of September 2010, the Act requires private insurance plans to provide obesity screening for all adults and children without charging coinsurance or copayment fees. Services must be delivered by a network provider. Height, weight, and body mass index measurements for children also are covered as a preventive service.


Given that Americans now use preventive services at about half the recommended rate, often because of cost, these expanded benefits are a welcome development. At the same time, their availability will not replace patients' need for education, motivation, and follow-up. Nurses and nurse practitioners, with their strong training in patient education, can play an exceptionally useful role in this area.


The growing popularity and improved outcomes from bariatric surgery provide one option for reversing the negative effects of obesity. The research funded by the AHRQ has found that the average rate of postsurgical and other complications of bariatric surgery declined by 21% between 2002 and 2006.7 However, given the risks and costs associated with this surgery, nurses and other health care professionals advising patients should encourage and provide guidance on lifestyle modification first.


The obesity epidemic in the United States has been years in the making and crosses socioeconomic, behavioral, racial, and cultural lines. As the health care profession becomes more educated about how to address obesity in our patients, we have the potential of positively influencing the health and well-being of our patients for generations to come.




1. Centers for Disease Control and Prevention. Vital signs: state-specific obesity prevalence among adults-United States, 2009. Accessed August 11, 2010. [Context Link]


2. Agency for Healthcare Research and Quality. 2009 National Healthcare Quality Report. AHRQ Publication No. 10-0003. March 2010. Accessed August 11, 2010. [Context Link]


3. US Preventive Services Task Force. Screening for Obesity in Adults: Recommendations and Rationale. Rockville, MD: Agency for Healthcare Research and Quality; 2003. Accessed August 11, 2010. [Context Link]


4. Calfas KJ, Long BJ, Sallis JF, et al. A controlled trial of physician counseling to promote the adoption of physical activity. Prev Med. 1996;25(3):225-233. [Context Link]


5. Agency for Healthcare Research and Quality. 2009 National Healthcare Disparities Report. AHRQ Publication No. 10-0004. http// Published March 2010. Accessed August 11, 2010. [Context Link]


6. U.S. Department of Health and Human Services. The Affordable Care Act's New Rules on Preventive Care and You. July 14, 2010. Accessed August 11, 2010. [Context Link]


7. Encinosa WE, Bernard DM, Du D, Steiner CA. Recent improvements in bariatric surgery outcomes. Med Care. 2009; 47(5):531-535. [Context Link]