BMI and Obesity
BMI and Obesity Essay Paper
BMI and Obesity Essay Paper

Pathopharmacological Foundations for Advanced Nursing Practice-Obesity

Investigated Disease Process

According to WHO, obesity is a condition of excessive accumulation of body fat that impairs a person’ health with a BMI that exceeds 30kg/m2 (Chooi, Ding & Magkos, 2019). Its occurrence is attributed to increased calorie intake and physical inactivity where excess nutrients are converted into body fat. According to Hruby & Hu (2015), after smoking, obesity is the 2nd cause of deaths in the USA and increases the risk of the following chronic lifestyle illnesses: type 2 DM, cardiovascular diseases, hypertension and other diseases. In the USA, 34% of adults are obese and 30% are overweight.

Obesity is a global epidemic that is fueled by industrialization, urbanization, economic growth, sedentary lifestyles and transitioning to processed diets that are rich in calories (Hruby & Hu, 2015). It is a multifaceted issue that affects individuals, local and state institutions, healthcare providers, policymakers and leaders at the community level. Even though its causes and health impacts are well understood, very little has been done to promote efficiency and effectiveness in prevention and management(Chooi, Ding & Magkos, 2019). Therefore, it is a risk factor for increased mortality, additional healthcare costs, and other morbidities. There are however local and state programs that provide resources that can be used to address this epidemic and support communities to live actively and eat healthily by embracing lifestyle changes.

Pathophysiology

Although the pathophysiology of obesity is complex and not well understood, it is influenced by environmental and genetic factors and occurs following an imbalance in food intake and energy expenditure. Habits such as physical inactivity and sedentary lifestyles contribute to the buildup of excessive energy in the body. It has a complex pathophysiology involving a comprehensive interaction between neurotransmitters, hormones and cytokines (Heymsfield & Wadden, 2017). Cytokines are the small proteins that cells secrete to regulate communication. However, adipocytes form the basis of obesity within a cell. Adipocytes simply refer to fat cells that secrete hormones and cytokines referred to as adipokines.BMI and Obesity Essay Paper

The role of adipokines is to regulate the consumption of food, how lipids are metabolized and stored, blood pressure and the sensitivity of insulin. When fat accumulates in the viscera, the functioning of the adipocytes is interfered with leading to significant changes in how hormones are regulated and interact (Heymsfield & Wadden, 2017). As a result, changes occur in adipokines, neurotransmitters, and hormones, setting the stage for obesity. The complications of obesity are also influenced by the changes that occur in neurotransmitters, hormones, and adipokines.

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Standard of Practice

The most recommended obesity practice standard among primary caregivers requires collaboration between patients and caregivers. A primary care physician calculates an individual’s BMI using his/her weight and height as frequently as possible. BMI calculation informs the decision to counsel individuals with a BMI exceeding >25 (overweight) or >30(obese) to lose weight (Batsis et al., 2016). Another indicator of a high risk of cardiovascular diseases and type 2 DM is waist circumference. Waist circumference limit is 35 inches(women) and 40 inches(men). For both populations, behavior change through lifestyle modification is vital for weight loss. For example, patients can be advised on the appropriate dietary recommendations by suggesting evidence-based diets that are low in carbohydrates, sugars and fat and rich in fiber (Bray et al., 2016). However, weight loss guidelines depend on a patient’s assessment of a diet, pharmacological, physical activity, surgery, and counseling.

Pharmacologic Treatments

Introduction of Drugs

When dietary modifications and physical exercise fail to influence a person’s ability to lose weight among patients whose BMI exceeds 30kg/m2 or is more than 27 with underlying comorbidities, primary care physicians usually opt for pharmacological therapy. However, it is worth noting that most pharmacological therapies are meant for long-term weight management rather than directly managing obesity (Apovian et al., 2015). In my state, the evidence-based pharmacological treatments used are comparable to the standard guidelines of weight loss at the national level.

First Drug Category

The FDA approved orlistat and phentermine/topiramate as the 1st line drugs for weight loss management. The mode of action of orlistat is by inhibiting lipases in the GI tract to reduce the absorption of fat.. Orlistat, 120mg is taken thrice daily reducing up to 30% of the absorption of fat. As opposed to liquids, orlistat has increased effectiveness in inhibiting fat digestion in solids(Apovian et al., 2015). Its potential side effects are fecal incontinence and urgency, frequent defecation and oily stool. On the other hand, phentermine/topiramate is most indicated in weight loss management in people whose BMI exceeds 30kg/m2. Similarly, it is also used in people with a BMI of 27kg/m2 with weight-related underlying comorbidity(Apovian et al., 2015). It acts by influencing the release of norepinephrine and reducing its uptake in the hypothalamus leading to reduced food intake.

Phentermine is an adrenergic agonist that also acts by activating the sympathetic nervous system and increasing the amount of energy used while resting(Apovian et al., 2015). Topiramate, a medication approved by the FDA for the prophylaxis of migraine and epilepsy reduces weight by reducing the intake of calories and enhancing taste aversion(Apovian et al., 2015). However, this drug is contraindicated in patients with a cardiac history involving coronary artery disease and hypertension. Since it increases the risks of a cleft lip/palate among exposed infants, women of childbearing age must do pregnancy tests before taking it and use contraceptives during the entire period of management(Apovian et al., 2015). Phentermine/topiramate is further contraindicated in patients who have glaucoma and hyperthyroidism.

Second Drug Category

Lorcaserin, an SSRI is recommended for weight loss management in patients whose BMI exceeds 30kg/m2. It can also be used among those with a BMI of 27kg/m2 with weight-related underlying comorbidity. According to Apovian et al. (2015), lorcaserin acts by binding hypothalamic receotors to decrease a person’s appetite. Its potential sde effects include fatigue, constipation,nausea and dry mouth. One of its most significant adverse effects is the serotonin syndrome whose likelihood to occur is high among patients on SSRIs (Apovian et al., 2015).
Third Drug Category

The FDA approved the combination of bupropion/naltrexone for weight loss management in the year 2014. According to Apovian et al. (2015) ,the mode of action of bupropion is inhibition of the reuptake of norepinephrine and dopamine. On the other hand, naltrexone is an opioid receptor antagonist acts by inhibiting the neurons activated by bupropion for continued weight loss. Potential side effects are: headache, constipation, dizziness, insomnia, vomiting, and nausea. It is contraindicated among patients with seizures, uncontrolled high blood pressure, bulimia, anorexia nervosa and patients on narcotics for pain management(Apovian et al., 2015).

Local Outcomes

In Louisiana state, the obesity rate among adults is currently 35.5%. Therefore, it is ranked 5th among all other states nationally. Over the years, the prevalence has been increasing gradually. For instance, in the year 1990, the rate was 12.3% and 22.6% in 2000 (Myers et al., 2015). The steady rise is attributed to sedentary lifestyles and poor dietary habits within 40% of households. An estimated 40% of the adults in Louisiana do not eat fruits at least once a day while 23% rarely consume vegetables(Myers et al., 2015). Besides, less than 80% do not meet the physical activity recommended guidelines.

Clinical Guidelines

Obesity clinical guidelines emphasize conducting assessments, disease management, and educating patients. Bray et al. (2016) emphasizes on the need for to have a good understanding of obesity and its risk factors since its management requires behavioral changes through lifestyle modification for successful treatment outcomes. It also requires healthcare providers and patients to be knowledgeable and well educated about its management. The following are the commended guidelines for assessing, diagnosing and educating individuals about obesity.

Assessment

As supported by Adab, Pallan & Whincup (2018), during a patient’s initial visit, the primary care provider should complete a comprehensive medical history, take the BMI measurements and waist circumference. The history should also incorporate the family history, physical activity habits, dietary habits among other risk factors that can determine the cause of obesity.

A BMI is determined by measuring a patients weight (kgs) and height (m2 ) to assess a patient’s abdominal fat, a provider will measure the waist circumference(Batsis et al., 2016). Medical illnesses such as cushing syndrome, POS (polycystic ovarian syndrome) and hypothyroidism are risk factors for obesity. Therefore, the assessment should also include laboratory tests to check for the aforementioned illnesses.

Diagnosis

During routine hospital visits, all adults must undergo screening for obesity. In every visit, the provider must assess and record the waist circumference and BMI. Even though a person’s BMI doesn’t directly measure body fat or differentiate fat from muscles, it’s the most commendable approach to diagnose obese patients. Abdominal obesity is described as having a waist circumference < 35 (women) and <40(men). Patient Education Patient education on lifestyle modification improves outcomes and healthier lives. A patient has health benefits irrespective of whether weight loss is simple or significant of the overall body weight (Bray et al., 2016). To educate and assist patients on obesity prevention, the USPSTF developed the 5A's counseling approach as follows: 1) Assessing- conduct an assessment to determine obesity and underlying comorbidities, dietary and physical activity habits, readiness for behavior change and drugs that affect weight. 2) Advise- advising a patient about the diagnosis including options for diets to promote weight loss, the essence of reducing calorie intake, benefits and dangers of OTC weight-loss medications, surgery and significance of self-monitoring(Bray et al., 2016). 3) Agree- if the client is not ready, he should agree with the primary care provider to discuss on another visit. If he is ready, they should develop a plan for treatment and set weight management goals (10%) through medications, diet, and exercise (Bray et al., 2016). If he/she is a candidate for surgery on weight-loss, it is essential to review all options for surgery(Bray et al., 2016). 4) Assist- help the client to develop a dietary plan and physical activity guide. It is also essential to provide the patient with useful resources according to his needs and assist him to determine self-monitoring methods to use to observe his/her daily physical activity routine and food intake (Bray et al., 2016). The primary care provider should also review the patient's activity and food log and follow-up appointments to reassess if he/she has not achieved the goals 5) Arrange-organize for the patient's follow-up, possible referral to a surgeon, dietician, classes on weight management and a behavioral counselor to ensure that a patient does not regain weight after weight loss. Standard of Practice Disease Management Obesity and weight loss practice management standards in my community are the same as the national guidelines and practices used to manage obesity. Most PCP strictly adhere to the standard guidelines which involve taking a comprehensive medical history, conducting a physical exam, ordering for laboratory tests and prescribing medications where necessary. Obesity is diagnosed based on a patient's waist circumference and BMI, after which providers develop a plan for manageing weight depending on individual patient needs(Bray et al., 2016). There are also counseling and support groups which play a vital role in management by providing resources to improve knowledge and adherence to management guidelines. BMI and Obesity Essay Paper The community also advocates for a lifestyle change. Sensitization at the local level emphasizes on the significance of engaging in physical activities and good dietary habits to manage weight and control the BMI. The sensitization is done through educating leaders at the community level who later share with other community members, seminars, local radio and television channels. However, since there are no set national standards on physical activity and dietary preferences, the choices made vary by community and depend on individual needs. Managed Disease Characteristics and Resources The main characteristics of a patient who has achieved and maintained a healthy weight loss are a BMI that is within the normal range(18.5-24.9kg/m2), compliance to behavioral counseling and physician appointments, a minimum of sixty minutes of daily physical exercise, observing a regular healthy diet and having a reduced risk of associated comorbidities (Bray et al., 2016). Similarly, patients who have appropriately managed to lose weight will demonstrate appropriate skills for continued weight management. Most patients can access a primary care provider and a physical activity fitness center. The patients will also be knowledgeable to select the most appropriate and healthy foods and have the finances to purchase pharmacological treatments or even undergo bariatric surgery. According to current existing evidence, patients with a BMI exceeding 40 have a decreased life expectancy. Most of them die due to cardiovascular diseases, diabetes, and cancer. The life expectance of patients with a BMI of 40-44.9 decreases to 6.5 years while people with that of people with a BMI of <55 and decreases to 13.7 years (Hruby & Hu, 2015). However, when patients are appropriately managed, thir life expectancy increases. International and National Disparities Globally and in the US, obesity is an issue of public health significance. Approximately 40% of adults in South and Northern America aged 45-59 are obese. Although obesity is prevalent across all racial and ethnic groups, socio-economic status, gender, ages and geographic location, ethnic groups at high risk compared to the Whites are Latinos and black Americans (Myers et al., 2015). Obesity is a global epidemic whose management is greatly impacted by ability to access care, disparities in healthcare and care quality. Similarly, there are specific ethnic/racial behaviors across specific populations that increase the risk of obesity. Culture also influences obesity acros ethnic groups whereby, compared to Whites, non-Hispanic blacks are more satisfied with their body size. 48% of African American adults are obese, a percentage that is significantly higher than that of Whites (32%). The major obesity contributors among black Americans include lack of access to healthcare services, healthy diets, education and having a low income (Myers et al., 2015). Similarly, the major contributing factors to the high obesity prevalence among Latinos are limited opportunities to make healthy food choices, limited access to physical activity resources, healthcare inequity and lack of access to quality care. At the global level, disparities in the management of obesity are influenced by several socio-economic factors that impact public health. The most significant factors include the level of income, poverty, lifestyle choice, and education. In the UK, prevalence o obesity is currently 25%. (Krueger & Reither, 2015). This percentage is a bit lower than that of the US. After reviewing how obesity is managed in the UK, it was discovered that the assessment and diagnostic methods are similar to those used in the US. However, pharmacological therapy was different. The UK only uses orlistat for weight loss management (Bray et al., 2016). The UK government has also provided a toolkit that is used by healthcare providers to educate every patient on how to prevent obesity. The national government also advocated for increased physical activity. On the other hand, China has witnessed a steady increase in the rates of obesity every year. A comprehensive review of their obesity management standards reveals that the treatment options are the same as those used in the US. However, most Chinese are more prone to central obesity thus, the management standards following a diagnosis present a narrow BMI finding (Chooi, Ding & Magkos, 2019). For instance, in the US, the diagnosis of being obese follows a BMI > 30. However, in China, a person is diagnosed with obesity when his/her BMI > 28. Obesity can also be associated with the Chinese population since it is considered to be a sign of abundance and happiness (Chooi, Ding & Magkos, 2019). To address the obesity epidemic in China, the government has put in place different education programs that individuals are urged to participate in actively. BMI and Obesity Essay Paper

Managed Disease Factors

The ability to manage obesity is influenced by numerous factors including access to care and finances. As discussed below, these are the factors that influence the ability of patients to manage obesity, attain their goals and maintain healthy lifestyles.

Financial resources- clients with adequate financial resources to seek care from primary healthcare providers, eat healthily, pay for gyms, purchase drugs and go for routine counseling services are consistent in care and show better health outcomes in terms of managing obesity and losing weight(Myers et al., 2015). Thus, continuity in care of obese patients results in good weight loss management.

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Health Insurance- patients who are insured can use their health insurance to pay for services in weight loss management such as counseling, buying drugs and undergoing bariatric surgery (Chooi, Ding & Magkos, 2019). For example, a patient covered by Medicaid can decide among several treatment options available for managing obesity since all the direct and indirect costs will be met by the federal government

Access to care-accessibility to a primary healthcare provider for obesity management services is crucial. PCPs conduct periodic health assessments and decide on the most appropriate way to manage a person’s obesity based on his/her needs. Access to healthy food stores, fitness centers is also vital in maintaining a healthy lifestyle (Hruby & Hu, 2015). Therefore, being accessible and committed to the guidance from a PCP will result in good weight loss management and maintenance.

Unmanaged Disease Factors

Similar factors can hinder patients from adequately managing obesity as discussed below:

Care access- accessibility to the healthcare services is a vital factor in managining obesity. Besides, patients should also be accessible to food stores to purchase healthy foods and fitness centers for regular physical exercise. Lack of access to such essential services may be caused by inadequate finances, inadequate weight loss providers, transport services, lack of food stores with healthy foods, and lack of fitness centers. According to Chooi, Ding & Magkos (2019), when patients cannot access the aforementioned services, they cannot obtain the appropriate knowledge, information and healthcare services to manage obesity.

Financial Resources – Patients with inadequate financial resources cannot seek physician assistance to manage obesity, purchase healthy food, pay for gyms, undergo bariatric surgery, counseling or purchase prescribed drugs.

Health Insurance – uninsured patients probably due to poverty or lack of adequate income will rarely seek care for managing obesity. With insurance, an individual can pay for essential services such as prescribed drugs, bariatric surgery and physician visits(Hruby & Hu, 2015). However, when patients lack insurance, obese patients cannot receive the appropriate care.

Unmanaged Disease Characteristics

Even after attaining a weight management goal, patients should continue with weight loss management. However, most patients experience difficulties maintaining healthy lifestyles and as a result, they either never lose weight or regain weight. Hruby & Hu (2015) highlight that, patients may exhibit the following characteristics with time: sleep disturbance, emotional stress, breathlessness, joint pains, back pains, and excessive sweating.

To add on, obese patients are at a high risk of chronic lifestyle diseases such as type 2DM, cardiovascular diseases, hypertension, osteoarthritis, GI abnormalities and some types of cancers. Obesity is also a hindrance to care accessibility. For instance, there are weight limits of up to 450 pounds on MRI machines. Research also reveals high mortality rates among obese patients such that. The high surgical mortality rate informs the decision among most surgeons not to operate on obese patients(Hruby & Hu, 2015). This knowledge improves the understanding that most of the risks and comorbidities are associated with the inability to manage obesity.

Patient, Family & Population

Patient

Obesity has negative effects on individuals, families and the population. Obese patients have trouble moving around due to being overweight. As a result, their ability to perform activities of daily life is limited. Most people perceive obesity as a disease of people who are careless with their lives resulting in shame and embarrassment (Phelan et al., 2015). It also leads to related comorbidities such as stroke, osteoarthritis, heart failure, asthma, pulmonary embolism among others. It has a huge health burden, impairs the quality of life and influences expenditure on health. BMI and Obesity Essay Paper

Obesity influences discrimination and an result to the occurrence of mental disorders such as problems in interpersonal communication eating and mood disorders which can negatively influence a person’s quality of life directly or indirectly. In other instances, discrimination due to obesity results in psychopathologies that enhance bulimia, overeating and associated problems(Phelan et al., 2015). Current existing evidence also suggests that obesity among adult men and women increases the risk of poor sexual health. Most of them associate their physical appearance to their weight and experience difficulties engaging in sexual activities. According to Phelan et al. (2015), the outcomes of sexual health and sexual activity such as unintended pregnancies, sexual satisfaction, and abortion are very significant issues.

The stigma and discrimination associated with obesity reflect in all aspects of life such as the structure of employment, education processes, growth and development, and healthcare delivery. Obese patients face ridicule, rejection and social bias from the public and primary care providers(Phelan et al., 2015). When seeking care, obesity influences the attitude of healthcare providers and this determines how they provide subsequent clinical services. Obesity-related discrimination is in itself associated with poor dietary habits, which include binge eating, overeating, physical inactivity, and sedentary lifestyles, which in turn result in additional weight gain (Phelan et al., 2015).This vicious cycle increases the risk of exposure to weight-associated discrimination.

Although there are limited studies on obesity and how it impacts an individual’s spiritual health, current evaluations on the association between a patient’s spiritual well-being and emotional eating illustrate that low spiritual-well-being levels relate to high emotional eating levels. This happens, particularly in women. The evidence further suggests that emotional eating is a major contributor to impaired nutritional behaviors like binge eating, high intake of calories, and bulimia(Phelan et al., 2015). It is for this reason that other researchers emphasize the essence of educating patients to improve their spiritual perception.

Family

Obese patients are at a very high risk of developing related comorbidities like cardiovascular diseases, high blood pressure, type 2 DM and some types of cancers. The resulting complications from these comorbid conditions may force them to take a break from work permanently or more frequently and this negatively affects their source of income (Tremmel et al., 2017). Due to a lack of income, a patient will need assistance from family members. Additional financial issues that might arise from medical expenses impacts negatively on household income and expenditure.

Population

In my community, an estimated 30% of adults are obese and African Americans carry the huge burden. The high prevalence has influenced an increase in direct medical costs in terms of diagnosis and management. These costs are likely to increase with a progressive increase in the levels of obesity. The community has also recorded a significant increase in obesity-related comorbidities whose mortality and morbidity rates are significantly high(Tremmel et al., 2017). Obesity-associated comorbidities have direct and indirect costs on the population. The direct costs are associated with diagnosis and management while indirect costs arising from loss of productivity, absenteeism, welfare loss, presenteeism, high rates of disability benefit payments rates, premature mortalities and loss of quality-adjusted life years(Tremmel et al., 2017).

Costs

Obesity and its related comorbidities have an impact on the economy. According to Tremmel et al. (2017), the costs are grouped into four including transportation, direct medical costs, productivity and human capital costs and impact patients, families and communities at different levels.

Patient Costs

Obese patients incur direct medical costs linked to the diagnosis and treatment of obesity and related comorbidities. Previous studies estimate that obese patients are likely to spend 42% or more on medical-related costs as compared to their healthy counterparts. Generally, the annual related costs increase by 37% whereby, Medicare incurs 36%, Private pay-58%, and Medicaid-47% (Tremmel et al., 2017). Diagnosis and management costs differ depending on a patient’s plan of management. Obese insured patients only incur costs associated with deductibles and co-pays. Morbidly obese patients who require bariatric surgery and follow-up appointments are covered by insurance.BMI and Obesity Essay Paper

Private paying patients can incur significant costs. For instance, my community’s diet clinic does not accept insurance and charges $60 for a single visit. Other physicians within the community charge $70 for weight loss management. The prices of prescription drugs may vary or fail to cover the costs(Tremmel et al., 2017). For instance, a 30-day dose of phentermine is $22 from a local pharmacy while that of Naltrexone/bupropion ranges from $55-$200 while the average cost of bariatric surgery ranges from $10,000- $20,000(Tremmel et al., 2017).

Family Costs

Families with obese patients may incur direct or indirect costs since some patients may permanently lose income or partially work due to obesity-related comorbidities resulting in inadequate income. As a result, they require financial support from friends and families. As a result, families may be forced to make adjustments in household expenditures, which reduces family income.

Community Costs

The community incurs indirect obesity-related costs associated with decreased productivity, absenteeism, welfare loss, presenteeism, high rates of disability benefit payments rates, premature mortalities and loss of quality-adjusted life years. For instance, according to Tremmel et al. (2017), in the year 2015, the approximated costs of manaing obese patients was $148 billion. Nationally, the productivity costs associated with absenteeism and obesity were approximated at $6.38 billion.

Best Practices

Best practices in managing obesity requires the use of appropriate pharmacological therapy, lifestyle modification, and patient education. Patient education should aim to improve the awareness and knowledge of patients on the significance of engaging in daily physical exercise, observing a healthy diet and ensuring weight control. Appropriate pharmacological therapy should involve the prescription of drugs for weight loss management and counseling on the need for compliance for successful outcomes (Heymsfield & Wadden, 2017). Lifestyle modification focuses on behavior change to observe healthy dietary habits and engage in daily physical activity. Similarly, the present guidelines and standard practice for managing obesity should be followed as this will also improve the knowledge of healthcare providers on the management of obesity.

Plan Implementation

The author’s present setting involves routine care to patients of all ages seeking primary healthcare services. Therefore, the selected intervention strategies for implementation are:

Developing a diet and physical activity plan for patients. The diet plan will be low in carbohydrates, fats, calories, sugars, and rich in fiber. The physical activity plan will incorporate moderate aerobic activity and exercises that strengthen muscles
There will be a collaboration with a nutrition counselor/dietician to guide and educate patients based on current care guidelines for obesity management and inform them of the significance of weight control and healthy BMI. The dietician will also assess the needs of every patient and help them to develop a specific dietary and physical activity plan for managing obesity. BMI and Obesity Essay Paper
Developing counselor and provider education programs depending on the most recent obesity management guidelines. These programs will be asynchronous and availed online as a learning module. Every year, the program will be updated based on the new standards to ensure that patients get the right information and appropriate knowledge on managing obesity. Therefore, patients will be educated on how to access personal health information online, empower them to make more informed decisions and be actively involved in planning for care.
Plan Evaluation

It is essential to evaluate the outlined implementation plan to determine the success of outcomes and areas for improvement in the best practice for obesity. Therefore, the following measures will be used to evaluate the proposed intervention strategies.

Normal weight and BMI limits for sex and age based on the current guidelines will be used to determine patients’ success off their physical activity and dietary plans before and after weight loss management.
Successful guidance of a dietician and counselor will be demonstrated through a patient’s ability to verbalize obesity management guidelines, making informed and healthy food choices, actively engaging in daily physical activity, compliance to medications and consistent participation in support groups.
The success of education programs will be illustrated through routine chart audits of obese patients demonstrating strict adherence to routine care management standards.
References

Adab, P., Pallan, M., & Whincup, P. H. (2018). Is BMI the best measure of obesity?.

Apovian, C. M., Aronne, L. J., Bessesen, D. H., McDonnell, M. E., Murad, M. H., Pagotto, U., … & Still, C. D. (2015). Pharmacological management of obesity: an Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 100(2), 342-362.

Batsis, J. A., Mackenzie, T. A., Bartels, S. J., Sahakyan, K. R., Somers, V. K., & Lopez-Jimenez, F. (2016). Diagnostic accuracy of body mass index to identify obesity in older adults: NHANES 1999–2004. International journal of obesity, 40(5), 761-767.

Bray, G. A., Frühbeck, G., Ryan, D. H., & Wilding, J. P. (2016). Management of obesity. The Lancet, 387(10031), 1947-1956.

Chooi, Y. C., Ding, C., & Magkos, F. (2019). The epidemiology of obesity. Metabolism, 92, 6-10.

Heymsfield, S. B., & Wadden, T. A. (2017). Mechanisms, pathophysiology, and management of obesity. New England Journal of Medicine, 376(3), 254-266.

Hruby, A., & Hu, F. B. (2015). The Epidemiology of Obesity: A Big Picture. PharmacoEconomics, 33(7), 673–689. https://doi.org/10.1007/s40273-014-0243-x

Krueger, P. M., & Reither, E. N. (2015). Mind the gap: race/ethnic and socioeconomic disparities in obesity. Current diabetes reports, 15(11), 95.

Myers, C. A., Slack, T., Martin, C. K., Broyles, S. T., & Heymsfield, S. B. (2015). Regional disparities in obesity prevalence in the United States: a spatial regime analysis. Obesity, 23(2), 481-487.

Phelan, S. M., Burgess, D. J., Yeazel, M. W., Hellerstedt, W. L., Griffin, J. M., & van Ryn, M. (2015). Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obesity Reviews, 16(4), 319-326.

Tremmel, M., Gerdtham, U. G., Nilsson, P. M., & Saha, S. (2017). Economic Burden of Obesity: A Systematic Literature Review. International journal of environmental research and public health, 14(4), 435. https://doi.org/10.3390/ijerph14040435

BMI and Obesity Essay Paper