Obesity and Disease in an Interconnected World: A Systems Approach to Turn Huge Challenges into Amazing Opportunities

Lifestyle diseases, a subset of non-communicable diseases (NCDs) are a result of the way we live, work and go about our everyday lives. Over the last several decades, our diets have become unhealthy, our lifestyles sedentary and many of us still use tobacco and abuse alcohol. These four risk factors have resulted in an everincreasing prevalence of five lifestyle diseases; namely obesity, diabetes, cancer, chronic lung disease and cardiovascular disease (CVD). As per the World Health Organization (WHO), NCDs have become the major contributors to higher morbidity, mortality and at the same time the single biggest obstacle to development globally. Furthermore, NCDs continue to increase in virtually every region of the world with the WHO reporting a higher burden in middle and low-income countries. Health promotion and preventive health approaches are proven effective strategies in reducing disease burden with lower costs compared to the cost of NCD treatment. However, NCD prevention and control cannot be done with diet control and increased physical activity alone. It requires action at multiple levels with health care providers and governments as leaders, along with stronger health care systems and multi-stakeholder involvement. To ensure that the interventions meet set targets; regular reporting, global monitoring and accountability are important.

The prevalence of obesity has markedly increased worldwide. We confront it daily: in our social interactions, in our work, everywhere we turn. It is an issue that has significant effects on our health as reinforced by the ruling of the American Medical Association in June of 2013 to classify obesity as a disease. Although it is essential to address this condition, it is extremely intimidating and difficult to manage due to its multifactorial causation, potential for comorbidities, associated stigma, and the need for lifestyle change- never easy to recommend or to do. This chapter will provide an overview: the What, Who, Why, and How of obesity etiology and management. Our goal is to provide the reader with a basic understanding and tools to enable him/her to participate in addressing this critical public health issue.

Modern lifestyles in the developed world have led to decreased levels of physical activity. In addition to the contribution, physical inactivity has increased rates of overweight and obesity, physical inactivity has independently been cited as the fourth leading risk factor for non-communicable diseases. In this chapter, we review current guidelines recommended by the Centers for Disease Control, and contrasts them with actual energy expenditures reported in research around the world. We highlight the relationship between physical inactivity, overweight, obesity, and non-communicable diseases. We also identify major contributors to the decline in rates of physical activity in recent years, including availability of public and private modes of transportation, occupational limitations on leisure time, increased time spent in sedentary activities, such as television watching and computer use, and barriers to purposeful exercise. Finally, we review some popular initiatives and recommendations for improving the frequency and quality of physical activity among Americans.

Normal quantities of adipose tissue are required in humans, as adipose tissue stores energy and contributes to endocrine and immune functions. Hormones and cytokines secreted by the adipose tissue, collectively known as ‘adipokines’, include adiponectin, leptin, tumor necrosis factor-α, interleukin 6, and plasminogen activator inhibitor-1. These secretory products play important roles in the maintenance of glucose and energy homeostasis. Both excess and deficiency of adipose tissue can have a negative impact metabolically. In the lipodystrophy syndromes, there is partial or complete loss of adipose tissue, which can lead to insulin resistance, diabetes and hepatic steatosis. Malnutrition due to starvation and anorexia nervosa has also been associated with manifestation of diabetes. In contrast, excess of adipose tissue in obesity has also been associated with insulin resistance, diabetes, fatty liver and cancer. With obesity on the rise globally, non-communicable diseases including cardiovascular disease, cerebrovascular disease, diabetes mellitus, dementia, cancer, and fatty liver disease have increased dramatically in prevalence and are rapidly becoming leading causes of death around the world. Thus, a normal amount and distribution of adipose tissue is required to achieve optimal regulation of metabolism and general good health.

Association of metabolic abnormalities including glucose intolerance, hypertension, central obesity and dyslipidemia comprise what is called “Metabolic Syndrome (MS)”. It is known that MS is a risk factor for both diabetes and cardiovascular disease (CVD). Non-alcoholic fatty liver disease (NAFLD) has also emerged as an important metabolic disease which is associated with both diabetes and cardiovascular disease. South Asian countries and particularly India have very high prevalence rates of MS and NAFLD. Moreover, the prevalence of type 2 diabetes and premature coronary artery disease is very high. However, the link between MS, NAFLD and CVD are not very well defined. This chapter reviews in detail the association of MS with CVD and also NAFLD and CVD. It also discusses the controversies with MS and highlights current strategies involved in management of MS and NAFLD.

Type 1 diabetes arises from the autoimmune-mediated destruction of the pancreatic beta cells leading to a state of insulin deficiency. Type 1 diabetes is estimated to represent 5-10% of all the cases of diabetes, with an incidence that is rising across the globe at a rate of 3-5% annually. The cause of type 1 diabetes is uncertain, although it is believed that both a genetic predisposition and an environmental trigger(s) are necessary for the development of the disease. Treatment of type 1 diabetes requires insulin therapy, along with healthy diet and exercise habits. The amylin analogue Symlin is also approved for use in conjunction with insulin, and metformin and incretin mimetics are also being investigated. Insulin use requires close monitoring of blood sugar levels, with studies indicating that the best control in type 1 diabetes is seen in patients who monitor their blood sugar more frequently. Potential complications from type 1 diabetes include microvascular, macrovascular and psychological complications. Such complications are more severe in resource poor populations, often located in the developing world, which have inadequate access to consistent insulin and testing supplies. With adequate management of glucose levels, many such complications can be prevented. There is currently no cure for type 1 diabetes, although immunotherapy agents (including anti-CD3 mAb, CTLA-4 Ig, and anti-DC20) hold promise. Transplantation, including that of the whole pancreas, islet cells or stem cells, holds promise but issues exist with all modalities, which limits the cohort of patients for whom they may be appropriate.

Obesity is a growing epidemic affecting many races and nations. This rise is a major risk factor for many diseases including cardiovascular disease (CVD), diabetes mellitus (DM), certain malignancies and non-alcoholic fatty liver disease (NAFLD). NAFLD is now the most common cause of chronic liver disease in the US and many developed nations. Coexistence of DM and NAFLD can lead to progressive liver disease although mortality is usually due to CVD. The majority of NAFLD patients do not have progressive disease and liver biopsy is required to diagnose those individuals with non-alcoholic steatohepatitis (NASH) which can advance to cirrhosis and its complications. Several dietary, environmental and genetic factors may be important for the development of steatosis and progression of NASH. Although there have been several important observations regarding the pathophysiology of NASH, our understanding remains incomplete. Evaluation of NAFLD should include an assessment of contributory disorders such as metabolic syndrome and evaluation to rule out other causes of liver disease. The management of NAFLD is challenging as there is no effective drug therapy, and although lifestyle modification is often prescribed, clinical efficacy is usually low.

The global rise in obesity has generated interest in nutrition and behavioral therapies as care processes for managing obesity and related co-morbidities. Growing evidence supports the use of nutritional consultation and intensive behavioral therapy to reduce risk factors associated with obesity. The World Health Organization recommends that the delivery of interventions should be of appropriate intensity and sustained over extended periods of time while noting that even modest changes in risk factor levels may achieve substantial public health benefits. Obesity guidelines provide recommended steps for identifying risk status, matching treatment to risk assessment, and implementing weight loss intervention strategies. A highly collaborative process of care, which focuses on the nutritional and lifestyle management of obesity and selected co-morbidities, is known as medical nutrition therapy (MNT), when provided by a registered dietitian, or as nutrition therapy when provided by other disciplines. Behavioral therapy approaches that focus on collaborative decision making include motivational interviewing and the 5 A’s behavioral counseling steps. Motivational interviewing, which includes open-ended questions, reflective listening, affirmation and summarization, helps individuals address their concerns about making lifestyle changes. The 5 A’s steps generally include: Ask/Assess: ask about/assess behavior and health risk(s); Advise: personalize behavior change advice; Agree: collaboratively select goals, Assist: use behavioral techniques to aid in achieving agreed-upon goals and Arrange: schedule follow-up. Training programs can help health professionals develop nutrition and behavioral therapy skills and address bias and discrimination. Weight management approaches and priorities will vary by the risk status and health care settings.

Sleep is one of three pillars of health along with diet and physical activity. Lack of sleep and sleep disturbances are associated with a host of negative health outcomes such as diabetes, stroke, heart disease, obesity, cognitive decline, and accelerated aging of the brain. Given the shortening of sleep duration in the US and globally, associated adverse health outcomes are of concern. The focus of this chapter is on the impact of sleep on health, how much sleep is adequate, how sleep contexts affect the quality of sleep, the circadian clock system, strategies for keeping body clocks in tune through sleep timing, food, and sleep environment, and resources for assessing sleep. These resources include self-report tools such as short questionnaires as well as objective methods such as actigraphy. Major advances include understanding the impact of diet, environment, and the circadian system on developing optimal sleep patterns. Further research is warranted on assessment of sleep patterns globally as well as understanding the impact of diet, environment, and the body clock on improving the quality of sleep.

Inhabitants of Western countries are at an increased risk of energy imbalance, where processed and fast foods are the dominant food supply and the ability to make healthier food choices is clouded by persuasive marketing campaigns and a fast-paced convenience culture. Healthcare professionals and policy makers must take into account the vast behavioral, sociocultural, environmental, and genetic factors that influence dietary behavior and body weight. Food components to reduce include sodium, added sugars, and saturated as well as trans fats. Foods to increase include whole grains, fruits, and vegetables. Achieving these dietary recommendations requires effecting change at the individual, community, and global level.

There is overwhelming evidence for both the individual and societal benefits of a physically active lifestyle on maintaining high quality of life, decreasing the economic burden of sickness care spending, and reducing risk factors associated with non-communicable diseases. A 60 year historical review of the physical activity movement in the United States reveals movement from a focus on physical fitness as a means for readiness to serve in the military, to a dose/response prescription approach to physical activity for all ages, to the current evolution of an active living approach at the community level. There is evidence in many countries of the economic, human, social, and environmental benefits of a physically active community at both the societal level and all age levels: youth, adults, and older adults however a civic engagement process is necessary to develop a more physically active community and thus obtain these incredible benefits. There are ten key steps in the civic change process that any community can utilize to engage its citizens in a more physically active and healthful lifestyle. The steps rely on civic engagement, trust building, and sustaining community support. There are a host of websites and further reading to supplement the reader’s knowledge of current physical activity research, movements, and community engagement efforts.

Cardiovascular disease is the leading cause of death in the United States, overtaking communicable diseases, a trend that is likely to get worse. American Heart Association impact goals for cardiovascular health recommends behavioral modification pertinent to life style measures such as physical activity, diet, smoking, and alcohol consumption. Global burden of cardiovascular disease stresses the importance of public and private sectors and governmental involvement in addressing the problem. A heart healthy diet is of value in primary prevention of cardiovascular disease, based on the Mediterranean diet or Dietary Approaches to Stop Hypertension eating pattern. Dietary measures must be taken in conjunction with physical activity, with some physical activity always better than none. Smoking cessation is never too late to implement; physicians need to spend adequate time in effective counseling. Alcohol consumption is not to be encouraged; excessive drinking is harmful, while benefits may be apparent with alcohol consumption in moderate amounts.

Cardiovascular disease is the leading cause of death in the United States. The American Heart Association has an influence on goals for cardiovascular health, recommending behavioral modification as the foundation to heart health and medications as a supplement to prevent cardiovascular disease. Diet, in conjunction with physical activity is a vital component both for primary and secondary prevention and at any stage of the disease. Several new ACC/ AHA guidelines have been released in 2013 pertinent to assessment of cardiovascular risk, management of high cholesterol, addressing overweight and obesity status, and emphasizing the use of life style for these disorders. The 2013 European Society of Hypertension /European Society of Cardiology and Joint National Committee 8 guidelines for hypertension are also discussed in the chapter. Information is provided on women’s cardiovascular health, aspirin and omega-3 fatty acids.

The rapid spread and chronic nature of diseases of civilization have created a scenario where local and traditional medicine is ill-equipped to deal with health and wellness. Low cost public health prevention and intervention efforts are key elements in stemming the tide of diseases arising from fast-paced globalization. Diseases travel across borders, so do modalities of health. The mingling of Eastern and Western methods of health and wellness has given rise to the practice of various mind-body techniques. Yoga and meditation, categorized as mind-body therapies, are examples of this cross-fertilization of treatments between the East and the West. Both yoga and meditation have been described as useful and effective health and stress management tools that can alleviate the negative physical effects of stress by improving neuroendocrine status, metabolic function, inflammation, HPA regulation and parasympathetic nervous system tone. Yoga and meditation benefit health via their effect on obesity and diseases such as coronary heart disease and diabetes mellitus. The inexpensive nature of yoga and meditation practice makes them attractive public health tools. With the increasing impact of globalization, the arsenal of public health tools should include traditional and modern medical approaches from both Eastern and Western traditions. This sharing of regional and culture-bound health practices offersthe opportunity to implement potentially effective public health programs within unexplored geographic locations and settings. Yoga and meditation are ancient wellness techniques that can be used in combination with traditional medicine to reduce the global escalation of obesity and related chronic illnesses.

Aging trends reflect an older population characterized by increasing life expectancy. Aging is characterized by diminished physiological reserves and increasing co-morbidity, with outcomes tending to be worse in overweight and obese individuals. Older adults and especially the obese are on a large number of medications; these include prescribed and over the counter drugs. Providers require an understanding of the principles of appropriate prescribing for alterations in age related pharmacokinetics and pharmacodynamics. Body characteristics that influence drug actions include leaner body mass and changes in fluid and lipid compartment status; overweight and obese individuals therefore have altered kinetics and dynamics. Medications can cause both weight gain and weight loss. Polypharmacy is a common issue in the older population. The consequences of inappropriate prescribing and polypharmacy include adverse drug events and reactions, likely resulting in unwanted outcomes and hospitalizations. Prescribing medicines for obese individuals imposes challenges. Medication management must adopt principles to ensure adherence, surveillance, reconciliation and cost containment, with the aim to maintain quality of health care as well as safety.

The current chapter applies a systems thinking approach to define and study the dynamics underlying increased rates of obesity in Low and Middle Income Countries (LMICs). Systems thinking and dynamics modeling belong to the rapidly evolving, interdisciplinary field of system science research. This field adds value to more traditional public health research methods by contributing to the design and testing of integrated models of change, to examine how key factors interact with each other and with health status. We frame the problem of obesity for LMICs as an aggregate, chronic energy imbalance of the population as a whole, due in large part to increased consumption of highly processed foods. To begin to explore the dynamically complex nature of global obesity, we develop a causal loop diagram, supported by the extant literature, showing a comprehensive qualitative model of the dynamics underlying increased rates of obesity in LMICs. Eighteen endogenous factors, or constructs, make up these seven distinct loops. In addition, selected exogenous factors are shown, representing the effect of policies by foreign governments, global corporate entities, and other institutions that explain obesity dynamics in LMICs. We suggest that there are two major points of intervention to curb current increasing obesity rates: the first is to sustain or grow healthy food production capacity and the second is public health education.

Public health approaches to obesity have more recently been supplemented by incentive programs in the private sector. The experience in the U.S. and abroad will be discussed, including the reasons obesity has been a recalcitrant and increasingly common problem. The complex behavioral underpinnings and dynamics of over-eating will be described along with motivational strategies to change these by use of various incentive arrangements. Evaluating wellness programs and incentive schemes is difficult. To determine the return on investment in such initiatives will require well designed programs and evaluations which recognize potential biases and inherent ethical concerns. Further research will be crucial to bend the curve on rising obesity rates with their attendant costs.

Obesity is a global health problem. Interventions that work beyond controlled, intensive settings are needed to combat the obesity epidemic. The default behavior in obesogenic environments leads toward unhealthy diets and minimal physical activity. Interventions conducted in community settings have the potential to reach a wider population of adults and children; targeting both the individual and the environment. Community health centers, recreation centers, churches, and schools are community settings in which obesity interventions have been successfully implemented. Within community health centers, newer models of obesity care including increased provider and nurse training, remote support for weight loss, utilization of weight loss coaches, and community health educators show promise. Diabetes Prevention Program group interventions have been successfully disseminated through recreation centers such as the Young Men’s Christian Association (YMCA) and churches. In comparison to controlled intensive studies, the magnitude of weight loss and diabetes reduction in community settings yields more modest results. However, the impact of modest weight reductions disseminated at the population level can contribute to significant population level improvements. In targeting childhood obesity, changes in the school environment including changes to the food environment in schools, distribution of body mass index report cards to parents, and increasing physical activity in schools have all shown an impact in reducing obesity. Successful obesity treatment and prevention models that have been disseminated in community settings including healthcare, recreation, church, and schools will be reviewed.

Pediatric obesity is a significant public health concern. It is also, to some degree, designed into lifestyles that encourage sedentary behaviors and convenience. Our children move their fingers and their ideas across networks connected by electronic webs. Their social meet ups are often online and their friends are on Facebook rather than waiting on the field. E-culture is here and so are its consequences for children's well-being. The design of our healthcare system will need to adapt to the changing conditions of our world and help children re-design their behaviors to encourage healthy choices. Communities need to be engaged in developing environments to reinforce well-being. To address this significant public health issue, a systems approach to analysis and improvement is required. The first step is to understand the existing delivery system by documenting the patient’s experience, identifying environmental, social, and economic barriers and challenges to engaging them in their care and wellbeing. This should also include identifying lifestyle and infrastructure failures and leveraging opportunities to reinforce healthy choices and coordinated care. Every patient interaction should be viewed as an opportunity to improve health and wellbeing. New models of care will require that physicians take a proactive approach to managing patients’ health and wellness, collaboratively. Values, preferences, and beliefs should be considered in designing strategic health treatment plans that will engage and empower patients and their families; taking a life-course approach to care.

Health information technology is changing the way we deliver quality care, and improves our ability to access and treat patients, particularly those in remote or health resource-poor communities and those most at-risk. As healthcare providers, we find ourselves competing with businesses, friends and family members for the patient’s attention and time. To develop effective interventions, a systems approach to analysis and improvement is required that considers cultural, human and environmental factors. New models of care will require that physicians take a proactive approach to managing patients’ health and wellness, collaboratively. Our patients are constantly assaulted by stimuli, some of them traditional, others products of technology. To enable behavior change, we must devise effective methods of engaging our patients. We propose that healthcare innovations should be developed to focus on the patient’s experience and portability. The design of these innovations should promote competence and confidence and provide the requisite level of functionality required by the user. Effective innovations must begin with the patient. As appropriate, designing in certain elements, Gamification, Phygital™, and Social Engagement are essential to engage patients. Integrating these innovations into healthcare delivery can bring about definitive public health benefits.