One Disease, Many Causes: Social Determinants of Urban Obesity

Like many diseases, the disease of obesity is not a uniform condition but rather the result of interlocking causes that vary from patient to patient. A person’s upbringing, culture, access to information or lack of it, access to optimal nutrition or lack of it, psychosocial profile, exposure to pollution and stress, and a host of other factors may all act on whatever genetic substrate is present to promote obesity.

As healthcare providers (HCPs), it is important that we get to know an individual as a whole person, including external factors that will impact our care plan with them. Where people live will either help or hinder patients affected by obesity as they attempt to follow their HCPs comprehensive care plan for chronic management of their obesity, and urban settings give rise to some unique challenges for these patients.

The Built Environment

For obesity medicine in urban areas, one important factor to consider is the built environment that patients occupy: structures, parking lots, green or recreational spaces, waste areas, the types of businesses operating nearby, and so on. These elements can have an obesogenic effect.

For example, if a neighborhood has few grocery stores and many convenience stores, which typically offer energy-dense, highly processed, nutrient-poor food, that may make local residents less likely to maintain healthy eating patterns. If a neighborhood sprawls over a large area, with mostly paved areas and few recreational spaces, that will encourage car travel and discourage physical activity, promoting obesity. Air pollution in a given neighborhood may further discourage physical activity or even contribute to obesity by itself. Opening up a conversation about these factors will help the HCP create realistic care plans for their patients, optimized to the resources available.

The Social Environment

Physical surroundings are important to consider, but be aware that the social environment plays a role just as important, if not more, in promoting or inhibiting treatment of a patient's obesity. In urban settings, many challenges to obesity treatment are mediated through stress, especially in under-resourced areas. What is the poverty level of your patients’ neighborhood? How much violence occurs there? How much visible disorder is there, such as vandalism, abandoned cars or houses, or garbage?

All of these factors increase stress, and all are associated with increased behavioral triggers impacting nutritional choices, decreased physical activity, and as we would predict, increased rates of obesity. The neurobiology of stress gives us a likely explanation for this. Stress hormone pathways overlap with the brain’s regulation of appetite and energy maintenance, and high levels of stress have been shown to affect eating patterns.

Simply put, the social environments typical of disadvantaged urban areas mean patients in those areas will have to overcome greater obstacles, with fewer resources, to support the comprehensive care plan to help treat their obesity.

How to Help Patients with Obesity Living in Urban Areas

When designing treatment plans, HCPs should be careful to meet patients where they are and not overwhelm them by expecting too much. Set realistic goals that take into account the patient’s built and social environments, follow up with the patient frequently, and continue to advance your treatment program step by step when possible.

If you start to feel an individual is not implementing the care plan created using shared decision making, remember that there is likely a barrier present you may not know about. When we take the time to understand how social and physical determinants influence chronic management of obesity, we can provide better care for the individuals we treat.

Another key to providing better care and helping patients in different environments is knowing about developments in obesity medicine. Become a member of OMA, and learn to treat your patients affected by obesity by visiting us here. Continue your education advancement in this field and register for OMA’s fall conference today. This four-day event brings healthcare practitioners together so they can share expertise, earn up to 30 CME/CE, and stay on top of advancements in the field in regards to special populations.

Amy Ingersoll, PAC, MMS, is a nationally respected obesity medicine Physician Assistant. She has received the highest level of training in obesity medicine for PAs, the Advanced Education of Obesity Medicine certificate from the Obesity Medical Association (OMA). This certificate signifies expert knowledge of evidence-based obesity treatment approaches and an ongoing commitment to patients’ health. Amy approaches obesity as a chronic, progressive disease, with a focus on evidence based-treatment for long-term success. She has spoken at a national level on obesity medicine and was a subject matter expert for the American Academy of Physician Assistants’ Obesity Leadership Edge from 2015-2018. She continued her role as a subject matter expert in a collaboration with OMA and AANP for the creation of a Certificate in Primary Care Obesity Management for PAs and NPs. She is also founder of the PAs in Obesity Medicine special interest group and founder of the Arizona Obesity Organization.