Obesity has been, and continues to be, on the rise in America.

Adolescents, adults, and children have all shown substantial increases in weight gain since the 1960s.1 In 1960, the adult obesity rate in the United States was about 14%, and severe obesity was found in less than 5% of adults. The 1980s saw a large spike in the obesity rate, presumably because of the abundance of processed foods and more Americans eating outside the home. Rates have continued to increase. In 2018, the obesity rate was 42.4% and severe obesity was 9.2%.2,3

Obesity increases the risk for and/or severity of other diseases, such as certain cancers, diabetes, heart disease, and stroke. Respiratory illnesses, such as coronavirus disease 2019, pneumonia, and the seasonal flu, are exacerbated by the fact that many severely obese patients have difficulty breathing.4 The economic burden of obesity has reached record heights. The direct health care costs and indirect costs (eg, lost economic productivity) of obesity have become the greatest contributor to the burden of chronic diseases in the United States.5 In 2016, obesity accounted for $480.7 billion in direct costs and $1.24 trillion in indirect costs.5

Obesity is measured by body mass index (BMI). A BMI over 30 is considered obese and over 40 is considered severely obese. BMI is weight in pounds divided by height in inches squared, multiplied by 703.

CAUSES
Obesity is a complex disease as it has many risk factors, and patients who are obese often have a combination of contributing factors. Obesity is caused by excess fat, which occurs when caloric intake exceeds caloric expenditure.6

The diet of most Americans is too high in calories. Added sugars and processed foods contribute to this high-calorie diet.

RISK FACTORS
Genetics
The amount of body fat and where that fat is stored can have a genetic component. Genetics may also play a role in how efficiently food is converted to energy and how the body regulates appetite and burns calories.6 Also note that, although genetics may play a role, families usually share the same eating and exercise patterns.

Lifestyle Choices
An unhealthy diet consists of a lack of fresh fruit and vegetables, water, and whole grains. Added sugars (including in alcohol and sugary drinks), large portion sizes, too many calories, and too much fast food all cause weight gain.6

Sugar comes in different forms and has many different names. Some of these include brown sugar, corn sweetener, corn syrup, dextrose, fructose, fruit juice concentrate, glucose, high-fructose corn syrup, honey, lactose, maltose, molasses, sorbitol, sorghum syrup, sucrose, and syrup.7

Sugar is the most popular added ingredient in the United States. It is found in cakes, candy, cookies, other sweets, and in most processed foods. Some foods that have a surprising amount of sugar include bread, crackers, cured meats, ketchup, salad dressings, seasonings, and soup.7

Encourage patients to read the nutrition labels on the beverages and foods they buy. Although most people in the United States consume a full 3 cups of sugar per week, it is recommended that no more than 10% of daily calories come from sugar.7

Inactivity slows the burning of calories, resulting in a decrease in the overall amount of calories burned. Patients do not expend as many calories as they would if they were active, so extra weight can sneak up on them gradually.6

With today’s technology, it seems as if everybody is in front of a screen for most of the day, which is strongly associated with weight gain.6

Diseases and Medications
Some patients suffer from obesity caused by certain disease states, such as Cushing syndrome, diabetes, hypothyroidism, metabolic syndrome, and Prader-Willi syndrome.5 Other patients may lead sedentary lifestyles because of conditions such as arthritis, congestive heart failure, depression, edema, insomnia, and sleep apnea.6

When pharmacists see patients with these conditions, they should caution them about the weight gain that can occur. They should recommend that patients make appropriate changes to their diet and exercise regimens if they gain weight.

Many medications also cause weight gain. Patients often discontinue these medications as a result, which can create dangerous situations. Antidepressants, antipsychotics, antiseizure medications, beta blockers, and diabetes medications can all cause significant weight gain.6 Warn patients about weight gain when it is an established or suspected adverse effect. Advise them to try to lose or prevent the weight gain associated with some medications using the following strategies8:
  • Eat frequent, small meals. Six small meals focused on volume-rich foods, including nonstarchy vegetables, are better than 3 large meals every day. This allows for a variety of healthy foods and keeps the metabolism running.
  • Get good sleep. Encourage patients to practice good sleep hygiene and help them determine the optimal time of day to take their medications, so as not to interfere with sleep.
  • Increase potassium intake. Potassium helps to flush out sodium. Potassium-rich foods include avocados, bananas, beets, black beans, coconut water, edamame, potatoes, spinach, and sweet potatoes.
  • Make conscious choices about sodium. Sodium tends to increase fluid retention. Processed, canned, and fast foods are all packed with sodium. The average person in the United States ingests 3300 mg to 3500 mg of sodium per day whereas they should be consuming about 2300 mg.
  • Stay active. Regular physical activity is essential for overall health. If the patient is sedentary and is in poor health, advise them to consult a physician before starting a physical activity regimen.

Socioeconomic Factors
Many people in lower socioeconomic areas do not have convenient access to fresh produce. Grocery stores tend not to build in these areas, for a variety of reasons. There is also a disproportionate amount of unhealthy foods more conveniently available, with the existence of many fast food restaurants as well as packaged and processed foods sold in abundance.9

Encourage patients in these areas to go the extra distance to obtain fresh fruits and vegetables. If that is not possible, discuss the benefits of starting a garden. Even a container garden can produce healthy fruits and vegetables. Encourage them to cut out fast and processed foods and sugar and replace them with fresh, whole foods.

Other Issues
Several other factors that may contribute to obesity are age, lack of sleep, pregnancy, previous attempts to lose weight, quitting smoking, and stress.

Pharmacists can make a significant impact in counseling patients about obesity. From making simple recommendations such as those mentioned to having patients come to the pharmacy and check in once a week, pharmacists can be very influential.

REFERENCES
  1. Freedman DS; Centers for Disease Control and Prevention (CDC). Obesity––United States, 1988-2008. MMWR Suppl. 2011;60(1):73-77.
  2. Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of obesity and severe obesity among adults: United States, 2017-2018. CDC. Updated February 27, 2020. Accessed June 22, 2020. https://www.cdc.gov/nchs/products/databriefs/db360.htm
  3. Fryar CD, Carroll MD, Ogden CL. Prevalence of overweight, obesity, and severe obesity among adults aged 20 and over: United States, 1960-1962 through 2015-2016. CDC. September 2018. Updated November 21, 2019. Accessed June 22, 2020. https://www.cdc.gov/nchs/data/hestat/obesity_adult_15_16/obesity_adult_15_16.pdf
  4. Coronavirus disease 2019 (COVID-19): groups at higher risk for severe illness. CDC. Updated May 14, 2020. Accessed June 22, 2020. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html
  5. Waters H, Graf M. America’s obesity crisis: the health and economic costs of excess weight. Milken Institute. October 26, 2018. Accessed June 22, 2020. https://milkeninstitute.org/reports/americas-obesity-crisis-health-and-economic-costs-excess-weight
  6. Obesity. Mayo Clinic. February 15, 2020. Accessed June 22, 2020. https://www.mayoclinic.org/diseases-conditions/obesity/symptoms-causes/syc-20375742
  7. How much sugar do you eat? You may be surprised! New Hampshire Department of Health and Human Services. Accessed June 22, 2020. https://www.dhhs.nh.gov/dphs/nhp/documents/sugar.pdf
  8. Drillinger M. 7 ways to lose weight gain caused by medication. Healthline. Updated April 24, 2019. Accessed June 22, 2020. https://www.healthline.com/health/how-tolose-weight-gain-medicine#4
  9. Hilmers A, Hilmers DC, Dave J. Neighborhood disparities in access to healthy foods and their effects on environmental justice. Am J Public Health. 2012;102(9):1644-1654. doi:10.2105/AJPH.2012.300865