Clinical and Management Guidelines of Obesity:

A Pathophysiology and Pharmacology Investigation 

Obesity has risen to a crisis point in the United States. Prompted by excessive caloric intake, obesity is a condition in which the individual gains excessive weight and fat, with attendant changes in body’s appearance.  The excessive fat built up is both visceral and subcutaneous. Excessive fat storage results in outer cosmetic changes, which is displayed by wider and fatter hips, thighs, stomach and even fingers, among other areas. However, visceral fat or, inner fat expands around organs and is much more harmful. However, no chronic disease is so simple to define. The same applies to obesity. 

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The facts and statistics reveal that nearly one in every three people is either overweight or obese (Ogden et al., 2012). The obese population includes all socioeconomic classes, races, age and academic levels (Flegal et al., 2010). At a personal level, obesity negatively affects the longevity and fullness of an individual. Obese individuals often become the subject of ridicule, suffer social stigma. They suffer from access to different places and even have difficulties during air travel. However, it is not the quality of life of the obese individual that we should only focus on. The scourge of this dreaded disease affects the family of obese individuals. Often the innocent children of an obese mother get ridiculed at school or in front of the child’s peer group. At a societal level, obesity causes a range of impacts. Nationally, the obesity crisis negatively impacts the rising cost of healthcare. Both the drain in healthcare cost and negative impact of productivity at a national level can be seen replicated at the international level. As obesity is mostly linked with rising level of economic prosperity a nation encounters, after a period of sustained economic prosperity, such nation’s general health may suffer as a result of obesity. From a productivity standpoint, more often than not, an obese person may have less productivity in performing a manual job when compared with a similar skilled individual who is less obese. Thus, with the onset of obesity, a nation may lose some of its economic prosperity that may have brought the obesity at the first place. Therefore, it is of vital importance for us to better understand this disease from every dimension possible. Therefore, despite challenges, the study of obesity important is very important for the following reasons. 

Consider some statistics. Data from the Centers for Disease Control and Prevention report (CDC, 2012) reveals that the obesity rate has gotten out of control. Authors Odgen, Carroll and Flegal (2012) project that by 2030, 50% of adult Americans will be classified as obese. There are several measurement tools used to classify obesity, but possibly the most common clinical tool is measurement of the body mass index (BMI) ratio. The BMI ratio is a widely accepted standard of measurement for obesity. BMI is measured by taking a person’s weight in kilograms and dividing that number by their height in meters squared. This resulting number is compared to standardized BMI numbers. Table 1 displays the standard BMI ratios. For example, from Table 1 we can determine that a number above 25 is classified as overweight, whereas, a number found to be above 30 are reported as obese. Having these tools to categorize the intensity of obesity is important, as obesity carries with it many associated health risks or co-morbidities. 

Obesity health risk co-morbidities include heightened chance of developing diabetes, fatty liver disease, cardiovascular disease, some forms of cancer, stroke, gallstones, reproductive problems and raises the chance of earlier mortality. These complications alone make it urgent to better understand the pathophysiology of obesity. While the knowledge including pathophysiology of obesity has improved over the decades, we still lack the ability to manage this complex disease. The following pages will attempt to provide a better understanding about the social, behavioral, genetic, and environmental factors that contribute to an understanding of why we become obese. By improving our understanding surrounding the metabolic aspect and the roles genetics and environment play on obesity, we will be better prepared to provide treatment plans and strategies to combat obesity.


Obesity: Genes or Environment or Both

Existing argument over the causes of obesity is geared around two strong aspects: genes or environment. We will consider both. But first, let us better understand the basic definition of pathophysiology. Pathophysiology focuses on understanding the various manifestations of the disease. Pathophysiology strives to describe the biological and physical events impacted because of the disease and evident by many symptoms. Generally speaking, pathophysiology is concerned with the processes within the body that are revealed through symptoms associated with the disease such as insulin resistance associated outcomes of type-2 diabetes which is connected with the underlying issue of obesity. Let us consider the pathophysiology of obesity in further detail.

Hormonal Connection with Obesity

Obesity involves the dynamic relationship between hormones, neurotransmitters and cytokines (R&D Systems, n.d.). This interaction works when fat cells called adipocytes increase both in quantity and in size. In this modification state they secrete within the body hormones and cytokines. These secreted hormones and cytokines are called adipocytokines (R&D Systems, n.d.). The newly created adipocytokines along with other hormones that assist in regulating food consumption such as, lipid levels/storage, insulin levels, blood pressure and many other variables that effect the regulation of metabolism. Here, excess fat storage impacts the typical flow of hormones and cytokines. The excess visceral fat stored within the cavity of the abdominal wall around internal organs such as intestines, liver and pancreas causes a disruption to regulation of the hormones and cytokines. This leads to complex and chronic consequences of obesity.

The impact of obesity on the neuroendocrine regulation is critical in managing appetite and eating habits, metabolism, and body mass. This hyper complex signaling system affects the messaging from the hypothalamus. Hormones such as insulin, gherlin, pancreatic peptide YY (peptide YY), and leptin circulate in the blood. These circulating hormones signal to the hypothalamus which regulates metabolism and appetite. Increased levels of these hormones are associated with obesity. Let us consider how these hormones both influence and are impacted by obesity.

Insulin. Insulin is a hormone secreted from the cells of the pancreas which acts as an appetite suppressing agent of the hypothalamus. Insulin aids in the regulating process of carbohydrates. Insulin also aids in fat metabolism. Insulin works by stimulating glucose from the blood in tissues from fat, liver, and muscles. This is a crucial process in providing energy to the person. But, visceral fat disrupts insulin output. As a result, the appetite suppression ability is negatively impacted. When not hampered by visceral fat, insulin increases the usage of glucose in fat and muscle. In the obesity population, insulin levels are disrupted, lessened or lost and the ability to regulate glucose is harmed. This often leads to type-2 diabetes, a dangerous metabolic disease that many obese people suffer from. 

Ghrelin. Ghrelin is secreted from the stomach and stimulates appetite. When ghrelin levels are increased the appetite is impacted and plays a role in satiation feeling. Ghrelin is the hormone that drives the desires to eat. As this hormone flows to the brain it interacts with both the hypothalamus and the pleasure zone of the brain. In this dynamic interaction, the desire to eat is stimulated. Ghrelin levels rise and fall throughout the day. It sharply increases before eating and dramatically reduces after food consumption. This hormone, therefore, stimulates appetite and causes metabolism to slow which reduces the ability to use and burn fat. 

Peptide YY.  The peptide YY hormone is secreted out of the intestine. Like insulin, this peptide hormone works to reduce appetite and does inhibit the normal gastric motility process. Peptide YY circulates throughout the bloodstream after eating. During this process peptide YY binds to the brain receptors that cause the feeling of fullness and decreased appetite. This hormone also slows down digestion. This aids in the person limiting food intake. However, in the obese population, low levels of peptide YY have been found. This lower concentration of peptide YY increases appetite. Low levels of peptide YY are typically found in the obese population and those in the initial stages of type-2 diabetes. 

Leptin. Leptin an adipocytokines works at the hypothalamus to suppress appetite. Leptin also works to improve insulin sensitivity levels. Leptin is secreted into the blood by fat cells and impacts the receptors in the brain that effect the urge to eat. Leptin also plays a role in controlling the storage of body fat. As leptin is secreted by fat calls, obese people generally have higher levels of leptin than non-obese people. While leptin is a hormone that aids in suppression of appetite, and obese people tend to have higher levels of this hormone, the effect of leptin are not being transmitted to obese population as the benefits of leptin is not reaching the brain of the obese population. Thus, leptin has become a hormone that has been targeted in research endeavors with the hope to understand why the benefits of leptin do not reach many obese people.

Understanding the dynamic interaction these hormones have with each other and in isolation are an important aspect of ongoing scientific research dedicated to understanding the disease of obesity. Gaining a respect for the hormonal influences, and the overall cellular level activity of this disease will also help educate and empower individuals that suffer from obesity to appreciate the pathophysiology behind the disease as they attempt manage their obesity. Hormones are not the sole cause of obesity. That would be too simple. Learning about the complex connection with genetics, environmental, excessive unhealthy eating and other factors will go a long way in diagnosing, treating and evaluating patients that suffer from obesity.

Standard of Practice

Effective standard of practice is delivered by a team of healthcare specialists that have diverse training in treatment of obesity. This team of healthcare professionals ranges from the general physician to the specialist who manages the bariatric surgery to the physician that manages the comorbidities. These healthcare professionals strive to provide the best standard of practice to their obese patients. Standard of practice begins with the initial assessment of the patient. From this point the assessment will determine the appropriate interventions needed. Interventions include (i) meeting with a primary weight loss physician to outline a weight loss strategy or weight gain prevention strategy, (ii) meeting with a registered dietician to become educated on nutrition and healthy eating, and (iii) meeting with an exercise physiologist to increase physical fitness, among many other team members trained to manage obesity.  The focus of each member of the healthcare team is to drive the standard of practice effort to bring weight loss and weight management skills to the patient.

As each patient is different the healthcare professionals take great care in determining the appropriate protocol for the patient. The typical standard of care includes: (i) dietary interventions, (ii) weight loss surgery, (iii) pharmaceutical treatments, (iv) exercise therapies, (v) cognitive and behavioral therapy and (vi) weight gain prevention.  It is common for the suggested standard of care to include a multi-pronged approach toward treating obesity. 

For example, a patient’s standard of care could include a dietary intervention that is low carbohydrates, high protein, and is no more than 1200 calories a day. Additionally, the patient would have regular exercise commitment with the exercise physiologist, behavioral counseling appointments, and a prescription for the weight loss drug Contrave. This patient would also be expected to follow-up with the specific team members to receive regular assessment on the quality of life improvement and whether the therapies and interventions need to be modified for continued success. This follow-up assessment would be the opportunity for the healthcare team to determine if the patient needs additional changes to their weight loss drug prescription. As weight loss pharmacological treatments are an important component to the standard of care towards obesity. Let us consider the pharmacological treatments in further detail.

Pharmacological Treatments

Evidence-based treatments. Along with assistance with lifestyle changes, and weight loss surgery for obese patients in Texas, obese patients can also be prescribed weight loss medicine. Pharmacological treatments that are offered throughout Texas include a new drug approved by the U.S. Food and Drug Administration (FDA) called Contrave (FDA, 2014). This drug is designed to treat chronic obesity, alongside restricted diet and increased physical activity. It is approved for people with a BMI higher than 30. It has also been approved for patients with a BMI of 27 or higher and also has co-morbidity such as type-2 diabetes or high blood pressure. The medical community became excited on the approval of this drug because it is considered unique, different from other available anti-obesity drugs.  Contrave’s uniqueness comes from the fact that it impacts the hypothalamus reward mechanisms. This drug lowers the reward sensation or feeling the patient receives after eating, thus the pleasure gained from eating is lost or lessened. This in turn should assist in consuming lower daily calories. A University of Texas weight loss expert has recently commented on Contrave’s ability to impact the “addictive-like nature of eating” common to obese patients (Greenfield, 2014, para. 6). 

Another evidence-based anti-obesity drug available in Texas is called Lorcaserin, often referred to as Belviq. This medicine assists in weight loss by reducing the appetite. Clinical data shows, after one year of taking this medicine the mean weight loss was just less than 13 pounds when compared to the placebo group that had nearly 6.5 pounds (Ostrow, 2010).

Similarly, another weight loss drug prescribed in Texas is called Orlistat, or popularly referred to as Xenical. Orlistat works by limiting the percentage of fat your body absorbs from food consumption. In the United States and many countries outside of the U.S., Orlistat is available without a prescription in a lower dosage. This lower dosage is called Alli. Results from evidence-based research found Orlistat users had weight loss averages just less than 12 pounds (Advanced Diabetes, n.d.). This weight loss program also included lifestyle change. Users of Orlistat also had improved cholesterol levels and improved blood pressure. Those suffering with diabetes had limited control of blood sugar levels while using Orlistat. 

Alli, Orlistat’s non-prescription alternative has also shown to assist in weight loss in clinical trials. This anti-obesity medicine is also available throughout Texas. Research revealed that about 50 percent of people taking Alli and followed a reduced caloric diet lost about “5%” of excess body weight (Hensrud, 2015, para.10). This weight loss is classified as meaningful, because it is enough weight loss to begin reducing the risk of diabetes, cardiovascular disease and other co-morbidities of obesity. 

All of these anti-obesity pharmacological options act as additional tools in the treatment and care of obese patients. While Texans are lucky to have these medicines to assist in the obesity management, it comes at a cost. The cost is borne by the individual patient, because nearly all anti-obesity drugs are not covered by private insurance or Medicare. A report by Kaiser Health News (Andrews, 2015) found that even health plans listed under the Affordable Care Act do not cover weight loss medicines. One of the problems appears to be that insurance companies are hesitant to cover any type of medicine that does not have the immediate impact. Most weight loss medicine work over period of time, possibly years. Until the Affordable Care Act, private insurers, and Medicare recognize the need for an assorted bucketful of options in treating obesity, patients will have to consider the weight loss benefits of the medicine when compared to the cost they will incur to purchase the medicine.

Clinical Guidelines

Ten Step Guideline

In an effort to improve the standard of care in treating patients with obesity, healthcare providers have been encouraged to recognize obesity as a disease that requires comprehensive treatment. Physicians are encouraged to focus on all factors including high blood pressure, raised cholesterol levels and to be transparent and candid about the patient’s weight. But, by focusing on obesity as a chronic disease, the patient feels humanized and not judged as being lazy. In return, physicians humanize their patients as battling a disease that needs a multi-pronged approach in overcoming it. This open dialogue is a fairly recent aspect of obesity disease management that is empowering to all stakeholders involved.

There are many other guidelines that impart optimal healthcare to the obese patient. For this paper, I refer to an excellent guideline provided by the National Heart, Lung, and Blood Institute (1998). The guideline was a result of an education initiative on the clinical practice guidelines on the treatment of obesity. The guideline was co-authored by many experts in the field of obesity. The guideline provides a clear ten step approach for healthcare providers to follow as they provide support to their patients. It is a simple to use and easy to follow tool to assess and manage obesity. Key recommendations include guidance on behavior modification, physical fitness, diet and lifestyle therapy. The guide also details the standard practice of pharmacotherapy for obesity. 

As a registered nurse, I find these guidelines respectful to the patient, and easily adaptable to any setting that is involved in the care and treatment of obese and overweight patients. Moreover, at my facility, I have witnessed this approach with obese patients. The suggested protocol includes:

  1. Obtain the BMI of the patient’s height and weight measurement.
  1. Obtain the measurement of the waist circumference.
  1. Evaluate and assess the risk status of comorbidities the patient may have.
  1. Consider BMI, waist circumference, and comorbidities and determine if the patient should be treated or not.
  1. Actively communicate with the patient about motivation and willingness to lose weight. Consider the attitude of the patient, the support group of the patient, and discuss barriers to change in weight loss. 
  1. Discuss the importance of eating healthy, and maintaining a diet that does not exceed 1200 to 1600 calories a day. Personalize a plan based on the patient’s condition at the time of assessment.
  1. Highlight and discuss the important for increased physical fitness. Detail a physical fitness plan that will avoid injury, but will allow the patient to increase physical activity. 
  1. Educate the patient on documenting weekly food and activity in a record keeping journal. Patient should include the amount of time spent on weekly physical fitness, diet and eating amounts, and overall goals that physician and patient have discussed and agreed upon.
  1. Provide the patient with copies of all guidelines such as physical fitness, diet and food intake, and behavioral change diary. 
  1. Physician should record the patient’s biographical data and weight loss goals in a journal personalized for the patient. It is important for the physician to follow-up at each visit with questions about the weight loss goals, assess the compliance and success of the patient in losing weight and following the program. Schedule regular follow-up appointments with the patient at least once a month. 

The ten steps above assist in creating an atmosphere of empathy toward the patient. Obese patients require an active physician that is devoted to their holistic care. Communication between the physician and patient is crucial in establishing short-term and long-term weight loss goals, developing strategies to adjust to challenges in daily weight loss efforts. 

Additionally, assisting the self-empowerment of the patient through education is important. Teaching patients the importance of their BMI and any co-morbidity they may have helps in creating an environment for lifestyle change. Patient education could be nutritional brochures the patient takes home, providing information about nutritional classes held at local hospitals and their affiliates, as well as connecting patients together as part of a support group devoted to obesity management.

Standard practice of obesity management. Within my own community in Dallas, Texas, the standard practice of obesity management, is in line with other healthcare facilities throughout Texas and the nation. Also, within my hospital the treatment protocol of obesity patient’s follows the ten step guideline above. There are, however, some enhancements to the ten step guidelines currently in practice at my hospital and some of the surrounding area hospitals within my broader community. 

One enhancement includes the use of electronic software that patients can log into and record and update their regular weight, food intake, and exercise regime. These electronic records can be printed out and reviewed between patient and physician. Plus, relying on the electronic system, the physician also has the option to input goals and strategies outlined at the beginning of the weight loss program. 

In addition to these efforts toward obesity standards of care, my organization is comprised of health care experts that treat obesity as well as co-morbidities such as diabetes, high cholesterol levels, lipid and various hormonal issues, among others. My hospital provides obese patients with a full complimentary toolkit of options such as bariatric specialist, mental health counselors, and dieticians. These experts can assist patients who don’t want to have weight loss surgery. But, these experts also include a bariatric team of experts that perform weight loss surgery on patients whose BMI is found to be 40 or greater. Bariatric surgery will be performed on patients with BMI of 35 or greater if there is also a co-morbidity that the patient is tackling such as heart issues, diabetes, or sleep apnea, among many others. The bariatric team offers popular options such as the gastric sleeve, lap band, and other innovative surgeries for weight loss. These practices and standards are in conformity with state, national and federal guidelines.

Managed Disease Process

The Disease Management Association of America (DMAA) defined disease management as the collective coordination between medical interventions and “communications for populations with conditions” that require patient involvement in their own self-care as being paramount (Sprague, 2003, p.2). The aspect of self-care is crucial in obesity management. Self-care alongside the support of the physician sets the tone for a productive partnership toward devising an advantageous care plan. Obesity disease management focuses on limiting and preventing complications by relying on standards and guidelines that promote empowerment of the patient.  Obesity disease management has to harness the involvement of the patient toward his own health improvement. This is because the physicians, medicines, and surgeries alone cannot treat obesity. 

In general, a patient that presents with obesity will be advised to manage the disease with a multipronged approach. Interventions will be personalized based on the patient’s current health, co-morbidity risks, and personal goals. General intervention includes dietary changes, increased physical fitness, pharmacological options, bariatric surgery options, social and behavior modification. The patient’s physician will assist in recommending medical interventions as well as empowering and educating the patient on obesity and weigh loss factors. The physician should lead the communication by providing weight loss goals that are realistic and possible. General guidelines suggest weight loss goals of approximately 2 pounds per week while increasing physical fitness levels and incorporating overall healthier eating habits. 

Diet and exercise. Management of obesity must include both dietary changes and an improved exercise regimen. Long-term weight loss is particularly difficult without the incorporation of daily physical fitness. Exercise is crucial in the early stages of weight gain, because exercise can become restricted if the patient becomes morbid obese. Exercise can also be restricted if the patient is suffering from cardiovascular disease and arthritis for example, because the physical exercise may become too taxing or painful for the obese patient. Still, diet and exercise must be a part of disease management that is promoted by the physician and embraced by the patient.

Pharmacological options. As outlined earlier, anti-obesity medicine has proven to be beneficial to many obese patients. Weight loss medicine has proven to provide another layer of support especially if the patient reaches a weight loss plateau. The medicines have proven to be effective in treating co-morbidity issues that many obese patients suffer from. In addition to weight loss medicine, interventions include vitamins, supplements and various homeopathic treatments. Often these work to boost the patient’s natural state and provide a sense of control and empowerment to the patient. 

Behavior modification. Fundamentally, the cognitive approach to disease management is an empowering skill for the obese patient to learn. Behavior modification works by assisting the patient to identify the changes they must personally make to lose weight. This can be learned through self-help groups, goal setting, discussion and identification of problems and solutions, and self-evaluative process. Evidence-based research found that behavior modification resulted in significant results, numbers of nearly 10 percent in weight loss in just the first 20 weeks (Wadden & Foster, 2000).

Behavior modification framework is based on clear guidelines. It is specifically goal orientated. These goals can be measured and assessed. For example, an obese patient could specify a goal to walk three times a week for the first two months. The goal will either be achieved or it will not be. The patient will have to act in her own best interest and assess whether or not she fulfilled the goal. If the goals are realistic, the likelihood of the patient fulfilling the behavior modification target is high. For example, if the same patient suffers from lethargy due to obesity, a simple goal of walking to the mailbox every single day could be an initial target. This is a realistic target that is empowering and measurable. These types of structured behavior modifications interventions prove powerful in the long-term disease management of obesity. 


The research data on obesity points to a lowered life expectancy for obese patients. The reality is that those struggling to manage obesity will face challenges on every level. Whether personal, professional, social and cultural obesity is a disease that has not received empathy like other diseases. Statistically, for those suffering from obesity the outcome to lose weight are quite poor. Often there is initial weight loss, but the weight most times returns. While the prognosis is bleak, obesity crisis must be tackled aggressively. Patients must make their health a priority and address their personal obesity disease management protocol Steps include more exercise, to incorporating cognitive behavioral therapies to limiting the number of unhealthy processed foods in their diets. All these steps coupled with the support of a team of healthcare providers that establish goals and guidelines can assist in losing weight which can in turn empower the patient to continue to manage this disease proactively. 


American Samoa.  Samoa is a tiny U.S. territory located between Hawaii and New Zealand. This island nation is comprised primarily of Hawaiians, Pacific Islanders, along with a subset of Asians, and Whites also make up the islands diversity. American Samoa has gained prominence for a variety of interesting reasons. Let us consider those reasons. Many American Samoan athletes have left the island to play professional football with the National Football League (Randolph, 2013). These players are big, strong and powerful competitors. American Samoans are appreciated on the football field because of their large size bodies. So large are American Samoans, that the tiny island was ranked number 1 in a world-wide country comparison index for obesity. This island nation reports to have just under 75% obesity population living on the island (Hughes, 2013, p.2). This number one world ranking made headlines news and a corporation found a way to capitalize on the islands obesity crisis. Samoa Airlines began weighing their passenger before they board the plane. Based on their weight the passenger would have to pay additional “50 cents per pound, for … body weight” (Tracy, 2013, para. 6). 

There are several reasons for the Samoan obesity epidemic. The island lacks any substantial economic opportunities. The island nation relies on tourism and tuna fishing as the main economic driver, but this is also limited. The lack of jobs leads to severe lack of motivation for movement. Additionally, with tourism and western influence on the island, the Samoan palette has been influenced by western processed foods. Traditional Samoan diet which consisted of locally caught and grown fresh fish, meat, fruits and vegetables has been replaced by imports of frozen fish, meats, canned fruits, as well as increased consumption of processed sugar and flour products.  

The Samoan Government is addressing the obesity crisis by urging citizens to change their unhealthy eating habits by offering public education classes which also addresses co-morbidities such as diabetes, gallbladder, and high blood pressure. The government is also offering free to the public exercise classes. Besides these minimal interventions, the government is conducting an economic initiative that will include researching the issue of obesity. This study is due to be completed by 2017 (Territorial Economic, 2014). While the government is making some efforts to address the obesity epidemic, there are many disparities in treatment and management of the obese population.

The most prominent disparity for the Samoans comes from their identity and their belonging within the world. First, across the island there is a sense of being a second-class citizen. The societal status of a Samoans is similar to the Native American populations in America. Given this feeling of disenfranchisement, isolation, and lowness- all factors surrounding low self-identity and low self-esteem, initiatives to improve Samoan obesity epidemic is difficult to manage. Moreover, the Samoan culture embraces the appearance of large and fat as a sign of beauty, and a heightened status symbol. This nation of people has a physical disposition of being large built people. Thus, from a pure cosmetic perspective, the common Samoan is not bothered by appearing overweight or appearing obese. Making matters more complex, since big is a sign of beauty, unless the average Samoan is suffering from a separate health issue, there is no personal drive to take advantage of health checkups. Simply put, big in size is not a problem, rather it is culturally accepted. (Ringrose & Zimmet, 1979). Culturally there has been emphasis placed on eating and having large quantities of foods served for their leaders. This tradition has crossed over into the locals eating and serving large quantities of food in their daily lives (Pollock, 1992).

Finally, the lack of economic infrastructure on the island is crucial impediment to obesity management. Lack of finances restrict the government to provide comprehensive management that the epidemic requires. (Bloom, 1986). This lack of resource also impacts the efforts to train, hire, and educate healthcare providers that are specialized in obesity disease management to assist in tackling the obesity epidemic. Without proper trained healthcare providers on the island, the common Samoan will be forced to get to another island nearby, which is timely and beyond the cost of most citizens. 

These disparities should be addressed: (i) the inability of Samoan’s economic opportunities to pay for proper healthcare services, (ii) the lack of healthcare professionals trained in obesity care management to offer services to the needy citizens, and (iii) the inability to quickly educate and overcome the cultural acceptance of being overweight. These disparities become further accentuated when compared to the common U.S. obese patient that has access to healthcare professionals trained in obesity disease management, has access via a variety of stakeholders to afford obesity related healthcare, and has been educated and informed on the dangers of excessive weight and high BMI numbers. For the people of Samoan all these disparities must be addressed so that the obesity crisis can be treated and those vexed by obesity will have the tools to successfully manage their obesity disease.

Overview of Managed and Unmanaged Disease Factors

Obesity management is a chronic and complex disease that requires proactive efforts to manage it. This disease requires an intervention plan consisting of personal goals, monitoring and support from physicians trained in obesity management.

Managed Disease Factors  

Successful management of obesity should be a multi-pronged approach which should include (i) established relationship with healthcare specialist, (ii) self-led behavior modification, (iii) support system, and (iv) proactive relapse planning.

Obesity healthcare specialist. A primary care physician that is trained in obesity intervention and management is crucial in dealing with both short-term and long-term management care of obesity.  The physician not only addresses the necessary medical needs of the patient, but also provides the bridge between many supportive options. For example, the healthcare specialist can suggest support groups, dietary education classes, exercise and physical fitness trainers, and also mental health groups. When the obese patient takes advantage of these additional resources, the goal of managing obesity becomes possible.

Self-led behavior modification. Being self-led and directed is important for the individual patient to manage the complexity of obesity. This optimum with patient working alongside the partnership of health professionals to implement changes. These self-care efforts include reducing overall caloric intake, being honest, and accountable toward obesity management goals. The key to being self-led is accountable for behaviors that diminish weight loss opportunities. Such accountability could be creating a journal of caloric intake on a daily basis. Efforts must be made to be increasingly active, while these could range from traditional walking or swimming, creative exercise could include volunteering to help clean up a city park. These creative solutions not only increase the physical fitness, but it also improves social interaction. 

Support system. Social interactions assist in supporting the efforts toward management of the complex issues of obesity. Social interactions allow the opportunity to detail the personal journey, challenges, successes and failures with other empathetic voices. The support system not only acts as a sounding board, but from such supportive system is advice that can be garnered from others. Support can range from family, friends, and co-workers, to professional organizations that specialize in the treatment of obesity. These supportive connections also offer an expectation of success for the patient to cling to toward of health and obesity management.

Proactive relapse management. The support system also acts as a counter measure to relapse. Relapse within the obesity management process is very real. Relapse must be addressed in the initial stages with the healthcare professional. By addressing this factor, the healthcare professional and obese patient can proactively plan for such challenges.  The goal should be to minimize the length and intensity of the impact. Should a particular goal fail, such as, when breaking specific dietary restrictions, or not fulfilling specified exercise requirements, or not attending an expected support group meeting, it should be addressed via communication and must be dealt with an empathetic attitude. The attention should be the long-term strategy, and acknowledging these relapses, but creating strategies to avoid them. By planning for relapse, the individual is already making a commitment toward health and managing the disease well.

Unmanaged Disease Factors. 

This reality of obesity management is that it is a difficult chronic disease to manage. While there are multiple interventions, the disease is complex and not one single surgery, not one prescription weight loss medicine, nor, one behavioral modification is enough. It has to be a comprehensive approach to management. For example, while a team of experts may be prepared to intervene and assist the individual, if there are no self-led efforts, the healthcare interventions will not matter. There are too many examples of the unmanaged ability towards obesity. 

Such examples include a popular television show that chronicles the life of person’s weighing 600 pounds or more (TLC, n.d.). The subjects of these shows are a mirror into the world of unmanaged obesity. In these shows we witness the inability to complete basic hygiene, walk or participate in regular household activities. Although healthcare professionals take the extraordinary efforts to intervene with the latest in healthcare obesity interventions, the success rate is low. Besides performing bariatric surgery, the healthcare team provides supportive dietary and nutrition counseling, regular monitoring of the person, and home health care and physical therapy. All of these efforts are set into place, with the individual dedicated to weight loss. However, days, weeks, and months later after some successful weight loss, the obese patient relapses. The former unhealthy habits and behaviors return. It is only those that overcome the relapses can carry on to successfully return to managing the disease. 

On the contrary, however, those that stay caught in the cycle of relapse and intervention, over and over, are in an unmanaged disease state. This state is depressive, hopeless, and physically damaging to the person. Often resulting in many visits to a mental health counselor, emergency room, and sadly, ultimately, it ends in death. This is the condition of unmanaged obesity.

Patients, Families and Populations

This chronic disease not only affects the nation as it grapples with it, it also impacts the individual sufferer and family. Obesity impacts the adults’ parents in families as well as their children. Children and youth fighting obesity often have learned unhealthy food behaviors from their obese and overweight parents. Evidence reveals that children who are raised by obese parents are likely to become obese adults. Obese children and youth are an important subset of the obese population to consider further.

Children are expected to mature and contribute in the society. Whether through paying taxes, becoming innovators in research and development, or building new homes as an architect, these opportunities are difficult to complete as an obese individual. Young children damaged physically and mentally by obesity often need additional mental and social welfare support systems because of childhood bullying, depressive thinking, and a lowered self-esteem. In this sense, obesity is not just a physical appearance disease, it is a disease the impacts the physical, mental, and social attributes of the person. Obesity is a disease that left untreated follows a child from the growing years, until the mature adult years. The U.S. Centers for Disease Control and Prevention (CDC) projects over the next fifteen years, almost 50% of the adult population will be obese (Ogden, Carroll, & Flegal, 2012). This projection supports the fact that obesity is a difficult disease to manage. 

Children do not simply grow out of obesity. Obese children that suffer from co-morbidities such as gallbladder disease, diabetes, sleep apnea, asthma, mental health and behavior challenges, grow up to be adults suffering from these same complexities. The youth that suffers from obesity must tackle the natural pressures of fitting in, finding friends and figuring out life. These difficult growing pains are complicated if the child is suffering from elevated blood pressure, and can’t enjoy wearing fashionable clothing because no sizes are available for obese people. The middle school youth cannot participate in physical fitness class because the excess weight makes it impossible to run, bend, twist or move at the speed of the other classmates. The obese child will not be asked on a date, not invited to prom because being obese is an isolating disease. Classroom desks are too small, walking through the school bus aisle is challenging, and eating in the cafeteria is a horrifying event for the obese youth. These events plague the child through adulthood. The low self-esteem limits the dreams these children have for future college plans, employment plans and relationship plans. Many career paths will be off limits to the youth. From enlisting into the military, to working as a fireman, police officer, or to becoming an airline steward, all career paths off limits to an obese youth dreaming of a future. This impacts their future ability to pay for comprehensive health insurance coverage, to contribute into the system by paying taxes, and increases the likelihood that governmental assistance will be needed to manage their obesity. The economic cost of obesity is an important factor to consider. 


The financial cost for obesity is substantial. Research suggests that billions of dollars have been spent on treating obesity and co-morbidities related to obesity.  One report estimates “$450” billion dollars is spent annually on obesity (Chuang, 2011, p. 3). These obesity related costs add up quickly. Whether it is the government, society, individuals, families or employers, all are impacted by obesity and all are paying additional costs. 

Additional costs are incurred by the obese person by purchasing extra food. The obese person maintains their excessive weight by eating excessive calories. This adds up to additional fast food purchases, grocery store purchases, and restaurant eating out costs.  This additional food cost is reported at “$90” billion annually (Chuang, 2011, p.3). Besides extra food, the obese individual pays higher costs annually, “$30” billion for plus-sized clothing (p.3), specialized chairs, beds, and car seats to accommodate the body mass of the obese individual. These are just some of the extra specialized products needed to accommodate the size of the obese individual. The additional costs continue even as the obese individual tries to manage the disease. In the effort to manage and overcome obesity, many individuals participate in well-known formal weight loss programs such as, Jenny Craig, Atkins, Nutri-System, and Weight Watchers. These formal programs require specialized packaged food purchases and program enrollment fees. These formal weight loss regimes cost “$20” billion annually (Chuang, 2011, p.3). 

Since every aspect of the obese person’s living is affected, it is only natural that even their demise is also impacted by obesity.  Reports have found that obesity also costs more for plus-sized burial caskets, to costlier oversized vaults, and extra costs for funeral pallbearers.  As a funeral home must plan for pallbearers to carry the casket, the weight of the obese individual has to be considered. If a regular burial requires only four pallbearers, a burial for an obese individual may require up to eight pallbearers. This can nearly double the cost (Bowden, 2010). Burial costs can be “$2,500” dollars more for an obese individual (Bowden, 2010, para. 28). The economic crisis of obesity within America is apparent. From birth to the grave, the obese person pays a heavy price because of this disease.

Best Practice Promotion

Obesity is a chronic disease that is wreaking havoc on individual lives and creating immense economic strain on the healthcare industry. While obese patients struggle to fully lose all excessive weight, research has established that even moderate reduction in obesity level reduces health risks associate with the disease. Even with this knowledge, obese individuals struggle to successfully overcome and/or manage their disease effectively. Because of this, many individuals turn to fad diets or quick and easy solutions to their obesity. These unsuccessful attempts to lose weight compound the hopelessness feeling that the obese individual must manage. Thus, an appropriate best practice must treat the obese individual with an empathic touch that focuses on the holistic nature of the individual’s needs, while providing best practice interventions. Such best practice interventions should include diet and exercise counseling, behavior modification education, mental health counseling, support group networking, and specific weight loss goals managed by a healthcare professional trained in obesity management. In this case, I would advocate for nurse led obesity best practice interventions in as many healthcare facilities that can accommodate and support the individual needs.

As a nurse in a leadership role, I would like to see more personalized care given to obese patients. We must recognize their condition as needing specialized accommodation, creative solutions to their lack of mobility, shame and disease. With that in mind, I would like to promote changes that include scheduling appointment times when the waiting room is less active to ensure maximum space is available for their mobility needs. Proactively recognizing the physical limitations of the patient and setting up the examination room with obese appropriate blood pressure cuffs, examination table that can be lowered down so the patient does not have to step up, and ensure any gown or sheet needed is appropriate to the size of the obese patient. An additional change I would like to incorporate is creating a network of trust by arranging a mentor relationship between a nurse that is trained in obesity that will follow up with a telephone call, email, and video chat communication on a regular basis. Besides monitoring the basic health condition of the individual, the mentor will act as a support for the individual patient. These suggested simple intervention steps can be nurse led and nurse driven and can assist the obese individual in managing their disease.

Three Strategies and Implementation Plan

The best strategies must be built around forming trust and bond with the patient and their caregivers. The obese individual must feel dignity and empathy from the strategies set forth by their healthcare provider. The individual also wants to feel the healthcare team is educated and fully informed on the comprehensive nuances of obesity management. The following three best practice strategies strive to bring the patient back to a state of health and well-being. 

Strategy 1

Personalized clinic. Located in a first floor generously sized room – the clinic would be catered for obese individuals. All furniture, medical devices and tools, and staff would be geared toward humanely assessing, treating, and managing the needs of the obese clinic. Often, obese patients are expected to fit in the standard clinic rooms, using standard sized medical devices and being attended to by healthcare professionals not fully aware of the need of their obese patient. This clinic can act as a bridge between the patient and his or her primary care provider, and obesity team of specialist. Additionally, this clinic should act as a comprehensive clinic within the healthcare facility by offering specialized support group meetings, education classes, behavior modification classes, among other support efforts. This clinic specifically is devoted only to obesity and its management. Through this, the patient senses an elevated effort of care, empathy and empowerment that can result in moderate reduction in weight loss.

Strategy 2

Video chat healthcare. In an effort to recognize the fact that many obese patients cannot be accommodated in automobiles, cannot walk, cannot sit up, and require oxygen for breathing support – this innovative strategy will meet the patient in his or her environment.  By creating a tele-nursing strategy that specifically arranges appointments with obese patients via Skype, Facetime or any appropriate video chat facility the obese patient will be cared for.  A team of nurses trained in obese management would strategically arrange video chat appointments. These appointments will allow the nurse to view the patient, discuss health concerns and arrange for the mobile clinic (forthcoming) to follow-up with the patient. This strategy works to prevent the patient from remaining isolated and overcomes the weight bias that a patient could feel becomes of their inability to physical move. This is also a low-cost intervention strategy, which strives to become involved with the patient and address mental health issues as well. Through the video chat appointment, the nurse will be able to arrange for behavioral counselors to communicate through the video chat conference call option. Moreover, this strategy could act in coordination with the personalized clinic described above, and for those patient’s physically unable to come to the clinic, the video chat appointment could be arranged. Any support group meetings, educational lessons, or nutrition lessons offered in the personalized clinic, could be used in the treatment for those non-mobile patients that require specialized accommodation.

 Strategy 3

Mobile management. Thus far these strategies have attempted to accommodate obese patients in environments that humanely recognize their body size and lack of mobility.  This final strategy continues to recognize the fact that obesity often leaves the patient in a sickened condition in which they are homebound and bedbound.  The mobile clinic will be two vans that are modified with a lift, and can accommodate two obese patients should transportation be needed. But, the goal of the mobile clinic is to bring a nurse led team of two or three specialist to provide healthcare for the patient. The mobile clinic would include the lead nurse that documents and assess the health of the patient. Additionally, a physical therapist, a behavior and mental health counselor, as well as homecare specialist will be part of the team that would arrive to the patient’s location and provide obesity management care. The mobile clinic also works in collaboration with the video chat team and can arrange the initial set up of video chat conference call training for the patient. This would ensure the patient can remotely connect to the personalized clinic and the video chat nurse for all follow-up appointments and attend educational lessons offered by the personalized obesity clinic. This mobile clinic would also act as a reward system mechanism. With weight loss goals established and once the patient has successfully reduced enough weight that mobility is restored, the mobile clinic could be used to arrange an outing to a nearby park, gym, or library as an effort to bring the obese individual out of isolation and into mainstream society.

Evaluation Plan

All three strategies have been designed to provide comprehensive obesity management care to obese individuals. These three strategies have been designed to work in collaboration with each other to maximize the impact of best practice healthcare to the patients. To fully evaluate and judge the effectiveness of these strategies the following pilot program is suggested.

Pilot program. Select 7 obese patients for the pilot program. These patients could come through referral of primary care givers, bariatric surgeon specialist, and obese patients that have been treated in the emergency room. Of the 7 patients, three patients would be homebound and four would have mobility to receive treatment at the personalized obesity clinic. The pilot program would be established initially for a 6-month period. We begin with some initial plans.

Phase 1: Month 1-3

Obese and mobile. Initial BMI, weight, and waist circumference measurements will be documented along with a modest personalized weight reduction plan of 10 pounds each month as the target goal. Each patient selected for the pilot program will commit to the following requirements. 

(i) Complete a survey answering questions about expectations for the personalized clinical services, feelings about weight loss goals, expectations of the plan, and a brief narrative on thoughts and feelings of obesity as it relates to their lives.

(ii) Over the 6-month period, bi-weekly appointments are made at the clinic for regular health assessments and to meet and interact with the support team. 

(iii)  A mandatory attendance four times a month for nutritional, education, physical therapy, and emotional counseling interventions which will be offered on individual and group formats. 

(iv)  A mandatory video chat four times a month with a health care specialist to discuss progress, challenges, and any concerns.  

(v) A commitment to 30 minutes of exercise daily, these details will be personalized based on the original plan.

Obese and non-mobile. The same above mentioned protocol will be followed, except that a specific team of specialist will be trained to meet the patient in their home and initiate the set up for all video chat calls with the specialist team and all support group classes. 

Assessment: At the end of month three, an independent compliance specialist will document how many appointments were missed, how many educational classes were missed, compare the starting BMI and weight numbers with month three, and interview patients to obtain feedback on the program and whether or not expectations had been met.

Phase 2: Month 4-6

Phase 2 would carry on with the same mandate, except each patient would be expected to commit to 45 minutes of exercise daily. This phase will include a required opportunity for each of the participants to lead one weekly video chat support group session with the other members in the pilot group. This will drive the self-care and empowerment of the patient to be informative, informed and empathetic to others suffering from the similar debilitating impacts of obesity.  The participant will lead the video chat session similar to the style learned through the educational lessons given by the healthcare team during Phase 1.

Assessment: At the end of month six, an independent compliance specialist will document the findings for the full six month BMI and weight loss. Additionally, assessments will be noted on how many missed appointments were there. The assessment in this phase will also include how many video chat lessons were completed by each participant. This phase will include another interview with each individual member, but also include a group interview feedback session. The goal will be to hear about initial expectations and whether they were met or not. 

Success of the pilot program will be based on successful completion of the following specific criteria:

  1. No more than two patients dropped out of the pilot program. [ Yes or No]
  2. Minimum monthly weight loss was 7 pounds for each participant. [Yes or No]
  3. Non-mobile participant gained minimal mobility, based on physical therapist assessment. [Yes or No]
  4. Of the mandatory appointments required, missed appointments were no greater than 7.5% [Yes or No]
  5. Of the required participant led video chat classes, no more than 5.5% were not completed.  [Yes or No]

If these minimum standards are met, we would recommend the program to continue for another 6-months, and add an additional four obese and mobile participants, along with two obese and non-mobile participants to the program. During each phase the same assessments should be documented and evaluated to determine how to proceed, fine-tune, modify and improve the pilot program. 


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