Management of Obesity in Primary Care Settings The prevalence of obesity has reached epidemic levels in the United States and the human and economic toll of this condition is staggering. Besides the adverse effects that obesity has on quality of life in general, the condition is also highly correlated with a number of negative and expensive sequelae, including most especially diabetes and heart disease. While the research into the precise causes of obesity continues, most authorities agree that increasingly sedentary lifestyles and poor diet choices have exacerbated the problem. Likewise, many authorities also agree that primary care settings are the most appropriate for obesity interventions. This study proposes an experimental design in a primary care setting to evaluate the efficacy of an intervention using an activity monitor for a 6-month period in combination with other treatment protocols in reducing body mass index levels. The purpose of this study will be to develop an informed and timely answer to the proposed study's guiding research question, "For adult obese patients in primary care who have a BMI greater than 30kg/meter square (P), does using activity monitors (I), over a period of 6 months (T), produce greater weight loss results (O) compared to obese patients that do not use activity monitors (C)?"

Management of Obesity in Primary Care

On the one hand, innovations in healthcare technologies have nearly doubled the human lifespan over the past 170 years or so, and some authorities believe that American babies born today may live to be 150 years old or perhaps even older (Glor, 2012). On the other hand, though, the prevalence of obesity in the United States has become a serious public health threat that has numerous life-shortening comorbidities such as diabetes and heart disease that threatens to limit life spans among the young and old alike (Overweight and obesity statistics, 2017). Indeed, on average, more than two-thirds of American adults are considered overweight or obese, another one-third of American adults are categorized as obese and one-in-twenty is regarded as extremely obese (Overweight and obesity statistics, 2017). Against this backdrop, identifying cost-effective evidence-based primary care interventions for helping obese people lost weight and keep it off represents a timely and valuable enterprise as discussed further below.

Problem

The prevalence of obesity in the United States, like many other industrialized countries, has experienced a steady increase over the past 10 years together with the numerous adverse healthcare consequences that are associated with overweight and obesity (Sheesley, 2016). For adults aged 20 years and over, obesity is defined as a body mass index (BMI) in excess of 30 (Calculating BMI, 2071). Despite the need for additional research concerning the condition's precise causes, obesity is widely regarded as being a chronic, complex disorder that frequently requires multidisciplinary responses (Sheesley, 2016). There is also a general consensus that primary care is the optimal setting for obesity interventions (Gortmaker & Polacsek, 2015), and these issues form the basis for the purpose of the proposed study as described below.

Purpose

The purpose of the project is to reduce BMI scores among obese adults (BMI >30kg/meter square) by using activity monitors like a pedometer for a 6-month period and comparing these results to a control group that does not use an activity monitor in order to answer the guiding research question set forth below.

Question

The proposed study will be guided by the following research question: "For adult obese patients in primary care who have a BMI greater than 30kg/meter square (P), does using activity monitors (I), over a period of 6 months (T), produce greater weight loss results (O) compared to obese patients that do not use activity monitors (C)?"

Background and Significance

Obesity can cause substantially more complex medical problems for all patients, and may include costly comorbid conditions that can drive the costs of healthcare services up while diminishing the quality of life for patients and their families (Gortmaker & Polacsek, 2015). At present, the economic costs of treating obesity in the United States are around $150 billion a year, but experts caution that even these enormous costs may increase dramatically in the foreseeable future. In this regard, Zomosky (2013) emphasizes that, "Obesity-related healthcare costs could increase by more than 10% in 34 states and by more than 20% in nine states over the next 20 years" (p. 14). Furthermore, a member of the American College of Physicians' Board of Regents warns that, "Obesity is a much harder condition to treat than almost anything...

There isn't a... simple solution as there is with other common conditions we address in the primary care setting" (as cited in Zomosky, 2013, p. 15).
The sustained epidemic levels of obesity demand efficacious interventions, most especially in primary care settings (Gortmaker & Polacsek, 2015). Although implementing interventions for obesity in the primary care setting may not be the complete solution the complexity of the disorder requires, primary care does represent the best place to initiate the process (Gortmaker & Polacsek, 2015). Notwithstanding the severity of the need, however, there remains a dearth of timely and relevant clinical studies concerning the respective efficacy of different primary care setting interventions for obesity (Gortmaker & Polacsek, 2015), a gap that underscores the significance of the study proposed herein.

Literature Review

The BMI is calculated by dividing individuals' weight in kilograms by the square of their height in meters (Calculating BMI, 2017). The BMI is currently the most commonly used tool for estimating overweight and obesity in adults as shown in Table 1 below.

Table 1

BMI of Adults Age 20 and Older

BMI

Classification

18.5 to 24.9

Normal weight

25 to 29.9

Overweight

30 +

Obesity

40 +

Extreme obesity

Source: Overweight and obesity statistics, 2017

Although the BMI is not a direct measure of body fat, the U.S. Centers for Disease Control reports that, "In general, BMI is an inexpensive and easy-to-perform method of screening for weight category, for example underweight, normal or healthy weight, overweight, and obesity" (Calculating BMI, 2017, para. 3).

While a significant percentage of the general adult population in the U.S. is considered overweight or obese, there are some racial differences, with more black and Hispanic people being considered oversight or obese compared to white people (76.7% vs. 66.7% and 78.8%, respectively) (Overweight and obesity statistics, 2017). According to analysts at the U.S. National Institute of Diabetes and Digestive and Kidney Diseases, "Among adults in the United States in all racial categories, 68.8% were considered overweight or obese, 35.7% were considered obese, and 6.3% were considered to have extreme obesity" (Overweight and obesity statistics, 2017, para. 4). Moreover, although there have been some indications that obesity rates have stabilized somewhat since 2012, young adults in the U.S. still suffer from obesity at greater rates than their older counterparts (Daley & Brody, 2015).

As noted above, obesity is among the most difficult and complex conditions to treat, but there is general agreement among clinicians supported by a growing body of evidence that increasing physical activity represents an important component of any intervention for obesity today (Ducheckova & Forejt, 2014). In this regard, Pann and Yehl (2013) emphasize that, "Poor diet and physical inactivity have been estimated to account for nearly 400,000 deaths a year and are contributing factors to obesity" (p. 63). Consequently, a number of different assessment methods for measuring physical activity levels have been developed in recent years as part of obesity-targeted interventions (Ducheckova & Forejt, 2014).

Although these methods vary in expense and accuracy, Ducheckova & Forejt (2014) report that, "Of these methods, the pedometer provides a low-cost and user-friendly assessment of physical activity in terms of the number of steps" (p. 1070). Recent innovations in smartphone technologies have reduced the costs of formerly expensive pedometers to nearly nil or completely free, and these same innovations have increased the accuracy of these devices making their use in obesity-targeted interventions in primary care settings highly cost effective and valuable for recording physical activity levels (Ducheckova & Forejt, 2014). In this regard, Adams, Sallis and Norman (2013) point out that, "Pedometers are increasingly being linked to technologies (e.g. websites, mobile phones) and provide unique opportunities for the delivery of adaptive interventions" (p. 2). Moreover, pedometers are being incorporated into numerous studies concerning the efficacy of various obesity-related interventions (Adams et al., 2013).

Theory or Conceptual Framework

The Integrated Theory of Health Behavior Change will be used for the study proposed herein. The Integrated Theory of Health Behavior Change was regarded as the optimal theoretical framework for the purposes of the proposed study because "behavioral counseling and behavior modification can be an effective combination to produce moderate, sustainable weight loss" (Stantz, 2013, p. 58). The Integrated Theory of Health Behavior Change is also an especially appropriate for the purposes of the proposed study because a number of studies have shown that the use of pedometers has a motivational effect on obese individuals participating in primary care interventions (Alfaris, Wadden & Sarwer, 2015).

Methodology

This section describes the study's methodology, including the experimental research design that will be used to develop a timely and informed answer to the above-stated guiding research question, as well as the sample and primary care setting that will be involved. In addition, a discussion…