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Guest Editorial: Emerging Data on the State of Obesity
The state of obesity continues to garner attention regionally, nationally, and globally. For example, West Virginia has begun an innovative campaign to reduce childhood obesity by rethinking physical activity and recreation. Even with signs of progress, stakeholders recognize more work is needed when it comes to reducing the percent of obese children in the state, which currently stands at 33.6.1 As such, more than 365 schools in the state have joined the Alliance for a Healthier Generation’s Healthy Schools Program. In addition, Move to Improve, a program that allows students to participate in 30 minutes of physical activity each day, has gained support. This program and others across the country have begun to examine the extent and reasons for obesity in the United States.
The reason for concern is valid: according to data published in September 2015, rates of obesity now exceed 35% in 3 states (Arkansas, West Virginia, and Mississippi), 22 states have rates above 30%, 45 states are above 25%, and in every state more than 20% of the population is obese. Arkansas has the highest adult obesity rate at 35.9%; Colorado has the lowest at 21.3%. The data show 23 of 25 states with the highest rates of obesity are in the South and Midwest.1
At more than 14%, West Virginia has the highest rate of diabetes.2 The Centers for Disease Control and Prevention2 projects that 1 in 3 adults could have diabetes by 2050. According to data released in 2015, the 10 states with the highest rates of diabetes and hypertension are in the South. West Virginia has the highest rate of hypertension (41%).3
Adults ages 40–59 years have higher obesity rates (39.5%) than adults ages 20–39 and persons ages 60 years and older (30.3% and 35.4%, respectively). This is also true for severely and morbidly obese persons; people 40–59 years old have higher rates than people between 20 and 39 years and persons 60 years and older.4 Overall, 71.4% of Americans are overweight or obese and 3% to 10% (at least 8,000,000) are morbidly obese.4 The rates of persons who are severely obese continue to climb at a disproportionate pace, and this is occurring at younger ages.5
Worldwide, obesity has become an issue as evidenced by the emerging demographics of obesity among all categories of individuals.1 For instance, studies suggest a concerning increase in obesity among all age, ethnic, racial, and socioeconomic groups.5
It is no surprise an obesity crisis is plaguing health care in general and wound/ostomy care specifically. Many researchers suggest the trend will continue because lifestyles and nutritional habits have changed drastically in the past 50 years. For example, nearly 40% of today’s children and adults eat only 1 serving of fruits or vegetables a day.6 Americans living in the US consume an average of 640 fat calories per day.7 Sugar-sweetened beverages (SSB) have become pervasive; 5% of the US population consumes at least 567 calories from SSBs on any given day — equivalent to more than 4 12-oz cans of soda. SSBs make up nearly 11% of children’s and 12% of young adult’s total daily calories.8 Although the most commonly consumed SSB is soda, nontraditional SSB consumption — fruit drinks, sweetened bottle water, sports drinks, and energy drinks — also are experiencing a rise in consumption. Consumption of sports and energy drinks has tripled from 4% to 12% among adolescents.9
Obesity is one of the biggest drivers of preventable chronic diseases and health care costs in the US. Currently, this economic burden ranges from $147 billion to nearly $210 billion per year.1 From a wound or ostomy perspective, the literature explains the mechanisms by which obesity increases surgical and wound complications. Potential factors include the intrinsic anatomic properties of excess weight and poor vascularity of adipose tissue. Relative vascular insufficiency and subsequent decreased oxygen tension leads to decreased collagen synthesis, decreased capacity to fight infection, and decreased ability to support the necessary mechanisms of the healing cascade. These data have been available for at least the past 3 decades and are recognized as factors that delay healing. The literature suggests patients with a high degree of adiposity are at greater risk for a number of well-documented concerns than their leaner peers.10 Adipose tissue acts similar to an endocrine organ and influences hormone and cytokine production and secretion. Cytokines are cellular messengers that regulate various inflammatory responses. Dysregulation of cytokines, often observed in the obese patient, causes an environment of chronic inflammation. This dysregulation affects every organ of the body, including the intestinal tract, the integumentary system, chronic wound healing, and response to an acute illness.11
In her article in this issue of Ostomy Wound Management, Davis12 describes calciphylaxis as a condition characterized by calcification in the medium and small vessel arterioles. She reviews evidence pertaining to the relationship between obesity and calciphylaxis and the latter’s association with chronic kidney disease (CKD). Davis explains obesity was identified as a risk factor in 6 of the 8 studies she examined. One study found obesity increased the risk of calciphylaxis 4-fold. Although Davis suggests evidence is inconclusive to support the belief current epidemic rates of obesity, diabetes (diabesity), and chronic renal disease will predispose more patients to the development of calciphylaxis, she advises that until more information from calciphylaxis registries and other studies is available, clinicians should maintain a high index of suspicion when a patient presents with indurated, painful nodules or necrotic ulcers, especially if the patient also has CKD.
Levy et al13 contend that sitting-acquired pressure ulcers (PUs) are a common and life-endangering complication for individuals with obesity and diabetes, especially persons who chronically use a wheelchair. The authors explain increased body weight and diabetes-related alterations in weight-bearing tissue increase the risk for PUs and deep tissue injuries. The authors present results of a computer modeling study used to evaluate the biomechanical efficacy of an air cell-based cushion for individuals with tissue changes associated with diabetes and adiposity.
Regardless of the patients’ size, sacral PUs continue to present a challenge to the plastic or reconstructive surgeon. Lin et al14 describe findings from a retrospective case study of 11 patients who underwent inferior gluteal artery perforator flap surgery for sacral PU reconstruction. Because of tissue changes and associated comorbid conditions, it becomes essential to find innovative strategies to address these skin and wound care challenges.
As obesity continues to gain attention, wound and ostomy providers need to consider evidence-based strategies to manage the clinical, humanistic, and economic aspects of bariatric patient care. This issue of OWM seeks to identify some of those innovations.
References
1. Obesity Rates and Trends. Available at: https://stateofobesity.org/adult-obesity. Accessed December 1, 2015.
2. New Diabetes Atlas. Available at: www.cdc.gov/diabetes/data/index.html. Accessed January 6, 2016.
3. Hypertension in the US. Available at: https://stateofobesity.org/adult-obesity/. Accessed December 20, 2015.
4. Obesity Rates by Age Groups. Available at: https://stateofobesity.org/adult-obesity/. Accessed December 15, 2015.
5. Rimm A. Prevalence of obesity in the United States. JAMA. 2014;321(2):189.
6. State Indicator Report on Fruits and Vegetables, 2013. Centers for Disease Control and Prevention. Available at: www.cdc.gov/nutrition/downloads/state-indicator-report-fruits-vegetables-2013.pdf. Accessed December 21, 2015.
7. Loss-Adjusted Food Availability: Spreadsheets—Calories. Available at: www.ers.usda.gov/Data/foodconsumption/spreadsheets/foodloss/Calories.xls#Totals!a1. Accessed December 3, 2015.
8. Wang YC, Bleich SN, Gortmaker SL. Increasing caloric contribution from sugar-sweetened beverages and 100 percent fruit juices among US children and adolescents, 1988–2004. Pediatrics. 2008;121(6):1604–1614.
9. Han E, Powell LM. Consumption patterns of sugar-sweetened beverages in the United States. J Acad Nutr Diet. 2013;113(1):43–53.
10. Gallagher SM. Skin and wound care among obese patients. In: Bryant A, Nix D. Acute and Chronic Wounds. St. Louis, MO: Mosby;2015.
11. Gallagher SM. A Practical Guide to Bariatric Safe Patient Handling and Mobility: Improving Safety and Quality for the Patient of Size. Sarasota, FL: Visioning Publishers;2015.
12. Davis J. The relationship between obesity and calciphylaxis: a review of the literature. Ostomy Wound Manage. 2016;62(1):12–18.
13. Levy A, Kopplin K, Gefen A. The efficacy of air cell-based cushions in protecting against pressure ulcers in seated bariatric and diabetic patients: computer modeling studies. Ostomy Wound Manage. 2016;62(1):22-30.
14. Lin CT, Ou KW, Chiao HY, Wang CY, Chou CY, Chen SG, Lee TP. Inferior gluteal artery perforator flap for sacral pressure ulcer reconstruction: a retrospective case study of eleven patients. Ostomy Wound Manage. 2016;62(1):34–39.
Dr. Gallagher is a certified bariatric nurse, health care risk manager, and certified safe patient handling professional with more than 25 years of experience working as a registered nurse and consultant.
This article was not subject to the Ostomy Wound Management peer-review process.
