Elsevier

Preventive Medicine

Volume 68, November 2014, Pages 71-75
Preventive Medicine

Review
Obesity treatment in disadvantaged population groups: Where do we stand and what can we do?

https://doi.org/10.1016/j.ypmed.2014.05.015Get rights and content

Highlights

  • High risk disadvantaged population groups are at increased risk for obesity.

  • Current obesity treatment outcomes are below what is expected for behavioral interventions.

  • The use of telecommunications technology and material incentives may improve weight loss outcomes.

Abstract

Obesity is now the second leading cause of death and disease in the United States leading to health care expenditures exceeding $147 billion dollars. The socioeconomically disadvantaged and racial/ethnic minority groups are at significantly increased risk for obesity. Despite this, low income and minority individuals are underrepresented in the current obesity treatment literature. Additionally, weight loss outcomes for these high risk groups are well below what is typically produced in standard, well-controlled behavioral interventions and reach and access to treatment is often limited. The use of telecommunications technology may provide a solution to this dilemma by expanding dissemination and allowing for dynamic tailoring. Further gains may be achieved with the use of material incentives to enhance uptake of new behaviors. Regardless of what novel strategies are deployed, the need for further research to improve the health disparities associated with obesity in disadvantaged groups is critical. The purpose of this manuscript is to review the weight loss intervention literature that has targeted socioeconomically disadvantaged and racial/ethnic minority populations with an eye toward understanding outcomes, current limitations, areas for improvement and need for further research.

Introduction

In the U.S., the prevalence of overweight (BMI 25–29.9) and obesity (BMI  30) remains a serious public health problem. Obesity and overweight are related to the development of a number of chronic disease conditions with an estimated cost to the U.S. healthcare industry currently exceeding 7% of all health expenditures (Thompson and Wolf, 2001). Obesity has become the second leading preventable cause of disease and death in the United States, secondary only to tobacco use (US Department of Health and Human Services and Public Health Service, 2001). While an estimated 1 in 3 US adults are obese (Ogden et al., 2012), the socioeconomically disadvantaged and racial/ethnic minority populations are at vastly increased risk (Ogden et al., 2010). Data from NHANES, BRFSS and the Add Health study show large racial/ethnic differences in obesity, especially for women (Wang and Beydoun, 2007). Additionally, low socioeconomic status (SES) is an independent risk factor for overweight and obesity, particularly also in women (Flegal et al., 2012, National Center of Health Statistics, 2007). When obesity rates are categorized by SES (generally measured by income and education), there is a trend such that less educated women are more likely to be obese compared to women with college degrees (Ogden et al., 2010). Likewise when income and obesity rates are compared, women with incomes < 200% of poverty had higher rates of obesity than those 200% of poverty or higher (National Center for Health Statistics, 2007). All together, these data show the high risk for obesity particularly in low-income women. This high risk status has not, however, translated into greater research focus. In general, women are well represented in the weight loss and weight loss maintenance literature (Appel et al., 2003, Diabetes Prevention Research Group, 2002, Martin et al., 2008, Perri et al., 2008, Svetkey et al., 2003, Turk et al., 2009, Wing et al., 2004), but seldom are low-income groups targeted. As a result, there is very little evidence on how to efficiently and effectively promote and maintain weight loss for this high risk population (Kumanyika, 2008). This is true even though there is an otherwise expanding literature on obesity treatment. Achieving reductions in obesity rates for low-income and minority women is, therefore, of critical importance in lowering high obesity-related to social and healthcare costs, morbidity and mortality. Evidence suggests that lifestyle changes that produce even modest, sustained weight loss produce clinically meaningful health benefits and that greater weight losses can produce greater benefits. Sustained weight loss of as little as 3 to 5% is likely to result in clinically meaningful reductions in triglycerides, blood glucose and glycated hemoglobin and in the risk of developing type 2 diabetes. Greater amounts of weight loss will reduce blood pressure, improve lipid levels and reduce the need for medications to control blood pressure, blood glucose and lipid levels (Jensen and Ryan, 2014) (Foster et al., 2009, Goldstein, 1992). However, in the effort to eliminate health disparities, it is important to consider that one size does not fit all. The purpose of this manuscript is to review the weight loss intervention literature that has targeted socioeconomically disadvantaged and racial/ethnic minority populations with an eye toward understanding outcomes, current limitations, areas for improvement and need for further research.

Section snippets

Obesity treatment: the gold standard

Comprehensive lifestyle interventions for weight loss are delivered for 6 months or longer with the gold standard including on-site, high intensity (≥ 14 sessions in 6 months) treatment provided in individual or group sessions by a trained interventionist. Ideally, therapy should continue for a year or more (Jensen et al., 2013). Components of such interventions include 1) self-monitoring of diet, physical activity and body weight, 2) reducing energy intake, and 3) increasing energy expenditure (

Obesity treatment in disadvantaged population groups

Few weight loss trials that have been conducted in the U.S. have involved low-income minority (African American and Latina) participants (Bennett et al., 2012, Clark et al., 2010, Faucher and Mobley, 2010, Jordan et al., 2008, Mitchell et al., 2012, Ockene et al., 2012, Samuel-Hodge et al., 2013). Most of these trials have recruited participants from community or public health clinics (Bennett et al., 2012, Clark et al., 2010, Faucher and Mobley, 2010, Jordan et al., 2008, Ockene et al., 2012,

Treatment challenges

As stated previously, efficacy trials indicate that behavioral weight management interventions can result in clinically meaningful weight loss (Diabetes Prevention Research Group, 2002, Look AHEAD Research Group, 2007). Limited evidence is available however, on how to adapt these proven interventions to real world settings and diverse population groups (Akers et al., 2010). There are a number of challenges and barriers for low income groups that are commonly cited including lack of access,

Telecommunications technology

One possible solution to address a number of purported barriers to weight loss in high risk populations is the use of telecommunications technology. Researchers and clinicians have capitalized on the use of technologies such as the Internet and mobile devices to deliver weight management interventions. In the only study to date that directly evaluated the difference between on-line and in-person weight loss treatment, an intensive, web-based behavioral intervention produced an average weight

Conclusion

High risk disadvantaged population groups are at increased risk for obesity and the concomitant associated morbidity and mortality. The literature on how best to treat obesity in high risk groups is sparse with current outcomes well below what is expected for behavioral interventions. There is much speculation on the barriers to weight loss but little systematic evaluation of whether minimizing specific barriers actually enhances outcomes. Despite the current limitations, existing results

Conflict of interest statement

The authors disclose no conflict of interest.

Acknowledgment

This research was supported by National Institutes of Health Center of Biomedical Research Excellence award P20GM103644 from the National Institute of General Medical Sciences.

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