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Category: Obesity

Disparities in Obesity Management in Primary Care

Currently, around 90 million U.S. adults are classified as obese with a disproportionate amount of socioeconomically disadvantaged individuals affected. As recently proven, obesity can worsen COVID-19 outcomes alongside increasing the risk of cardiometabolic conditions, cardiovascular disease, type 2 diabetes, and other health conditions. Despite the significant disease burden placed on population health and the public health system, the management of obesity in primary care settings continues to lag behind that of other chronic conditions. Only recently has obesity become formally recognized as a disease, highlighting the need for improved prevention and treatment protocols across demographics and increased accessibility.

Obesity Management in Primary Care Clinics

Recently published in the New England Journal of Medicine, results of the Promoting Successful Weight Loss in Primary Care in Louisiana (PROPEL) trial advance the current knowledge regarding obesity management in primary care settings. The findings elucidate both the scope and intensity of interventions with a focus on underserved demographics.

The cluster-randomized trial examined data from 803 adults (67% black, 84% women) recruited from 18 primary care clinics across Louisiana. Participants were assigned to two groups, usual care and intensive-lifestyle intervention. Patients in the usual care cohort received routine medical care and health education materials throughout the course of the 24-month trial. Meanwhile, participants designated part of the intensive-lifestyle group received weekly counseling, personalized care, and tailored recommendations. This cohort received weekly counseling with 16 sessions conducted in person and 6 over telephone during the first 6 months of the trial. Afterward, they had monthly sessions through month 24.

Health coaches were trained by the research team and embedded in the primary care setting to deliver care and give patients personalized food-intake and calorie-intake targets. Patients were to weigh themselves daily using digitally connected scales and their nutritional and physical patterns were adjusted to help them meet their weight goals.

Intensive Lifestyle Interventions Show Real Results 

The study’s author noted a significant improvement in meeting weight loss targets when combined with strategic expert care. At the 12-month benchmark point, participants in the intensive-lifestyle group lost a mean of 6.75% of their baseline weight while those in the usual-care group only lost an average of 0.59%. In addition, participants within the intensive-lifestyle cohort reported significant improvements in multiple components of quality of life, including physical function and work.

Overall, the researchers’ findings revealed black patients lost approximately 2% less weight than patients of other races and ethnic groups at the 12-month mark. For the time being, the reasons for this disparity are unknown but experts believe they may include a lower resting energy expenditure in black women compared with that of their non-Hispanic white counterparts.

Out of the 803 total participants, 50.7% reduced their baseline weight by at least 5% – the best categorical weight losses observed in primary care studies, especially those involving socioeconomically disadvantaged patients. “Although patients in the intensive-lifestyle group in the PROPEL trial, on average, regained weight from month 12 to month 24, most likely because of the reduced frequency of counseling visits, they nevertheless maintained a mean 5% reduction at month 24,” the study’s authors noted.

The findings from the latest PROPEL trial reveal that it is possible for socioeconomically disadvantaged persons to lose clinically substantial amounts of weight when provided the intensive behavioral therapy and professional support necessary in primary care settings. The issue of how to ensure that all Americans, including those in underserved areas, receive the same reimbursed care for weight management that they have for other chronic conditions that stem from obesity – the root of the problem. The current lack of such targeted, accessible care contributes to the growing burden of widening health disparities in the nation which are only becoming more apparent in the face of a public health crisis.

The Impact of Obesity on Pediatric COVID-19 Illness

Lockdowns imposed due to the COVID-19 pandemic have had negative health implications for populations of all ages across the globe, resulting in an increase in cardiometabolic risk factors and decrease in mental health. Recent research points to the detrimental effect of the global pandemic on pediatric health, impacting dietary and sleep patterns as well as physical activity levels among children with obesity. At the same time, experts have long cautioned that being obese can greatly increase the risk of severe COVID-19 illness, highlighting the potentially dangerous correlation between lockdowns and pediatric health.

To date, international data indicate a lower rate of severe COVID-19 infection among children with higher rates of asymptomatic cases and significantly lower mortality rates. However, new findings implicate that the increased risk of illness associated with obesity may persist in the case of young patients. A new study published in JAMA Pediatrics, which evaluated the epidemiology, clinical, and laboratory features of COVID-19 patients, reports evidence of a clear association between severe disease and obesity in children.

Presentations of Severe COVID-19 Disease in Children 

Conducted by Philip Zachariah, MD, MSc, and his colleagues, the study was based on a retrospective review of electronic medical records from New York-Presbyterian Morgan Stanley Children’s Hospital with data from hospitalized children positive for SARS-CoV-2. Severe disease was defined as a case requiring mechanical ventilation. Of the 50 patients included in the study, 54% were male and 50% were Hispanic; 9 of the cases were defined as severe and two as extremely serious with 1 patient dying.

In the majority of patients, fever and respiratory symptoms – cough, shortness of breath – were present; in 44% of cases, gastrointestinal symptoms were reported as well. None of the 14 infants included experienced severe disease, while only 1 out of 8 immunocompromised patients developed severe symptoms. The study found that older children with an average of 14 years of age were more likely to develop severe COVID-19 infection, as were those with obesity – the most prevalent comorbidity in the cohort (22%).

The presence of obesity as a factor was significantly associated with the need for mechanical ventilation in patients above the age of 2; 6 out of 9 children who required a ventilator were obese. Participants with severe disease were found to have significantly higher C-reactive protein, procalcitonin, peak interleukin 6, ferritin, and D-dimer levels at admission.

No patients reported in the study developed a dangerous inflammatory illness which has been otherwise observed in rare cases in pediatric COVID-19 patients. In addition, the course of severe illness was noted to be relatively short with 76% of participating patients discharged within three days of admission.

Significant Role of Obesity

The study’s authors note that the sample size of the trial was small and may not be conclusively reflective of actual risk levels, limiting the generalizability of findings to a broader population of pediatric COVID-19 patients. However, the latest evidence adds valuable insight about the similarities in presentation and progression between COVID-19 infections in adults and children. While the majority of data confirmed previous hypotheses, evidence of obesity as a risk factor for severe disease and the need for mechanical ventilation highlights the significance of cardiometabolic variables in COVID-19 outcomes.

According to Dr. Zachariah and his team, expanding testing capabilities, maintaining high suspicion for COVID-19 infection, and risk stratification are necessary for the effective management of the novel coronavirus in pediatric patients. As more clinical evidence comes to light in the coming months, the wide-ranging impact of cardiometabolic conditions and risk factors on the progression of COVID-19 illness is expected to become more clear. In the meantime, clinicians should take into consideration the mounting indications of the potential for poor and even fatal outcomes in pediatric patients, particularly those with cardiometabolic conditions.