Running head: OBESITY IN BALTIMORE CITY

Obesity in Baltimore City

Angela Long
Coppin State University
Helene Fuld School of Nursing
Advanced Pathophysiology
Nursing 610
Dr. Arlene Johnson
November 24, 2012

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Obesity is a health problem that has become an epidemic over the last ten years that faces
one in three Americans. Obesity now competes with smoking as the leading cause in the United
States as preventable deaths. Obesity has been related to serious diseases which cause morbidity,
premature death and higher healthcare costs. The three leading causes of death are
cardiovascular disease, type 2 diabetes, and cancers; all are related to obesity (McCance,
Huether, Brashers, & Rote, 2010, p. 1477). Obesity is a disease which is affecting all races, ages,
and socioeconomic status worldwide.
By definition obesity is an increase in body fat mass greater than 30, an energy imbalance
with energy intake being greater than energy expenditure (McCance et al., 2010, p. 1477).
Obesity is a disorder of nutrition which causes are multiple and complex (McCance et al., 2010,
p. 1477). The pathophysiology of obesity evolves the interaction of many cytokines, hormones
and neurotransmitters (McCance et al., 2010, p. 1478). Adipose tissue secreted hormones and
adiopkines which regulate food intake, lipid storage and metabolism, insulin sensitivity, the
alternate complement system, vascular homeostasis, blood pressure regulation angiogenesis, the
inflammatory response, female reproduction, and regulation of energy metabolism (McCance et
al., 2010, p. 1478). A complex system controlled by a dynamic circuit of signaling molecules
including the brain stem, hypothymus and autonomic nervous system control regulation of
appetite and satiry regulating eating behavior, energy metabolism and body fat mass (McCance
et al., 2010, p. 1478). Any imbalance in this system can cause obesity. Obesity is associated with
increased circulating levels of leptin, insulin, ghrelin and PYY (McCance et al., 2010, p. 1479).
According to the Centers for Disease Control and Prevention, more than one third of U.
S. adults are obese which increases obesity related conditions such as heart disease, stroke, type
2 diabetes and certain types of cancers which are the leading causes of preventable deaths (p.1,
http://www.cdc.gov/obesity/data/adult.html). Marylands prevalence rate for obesity is 28.3% in

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2011 (p. 3, http://www.cdc.gov/obesity/data/adult.html). According to a data fact sheet released

by the Baltimore City Health department, one third of all adults in Baltimore city are obese and
one fifth of high school students are obese. This is a 66% increase in obesity from the previous
ten years for children and adults (p. 1, Fact Sheet: Overweight and Obesity in Baltimore City,
1997-2007, July 23, 2008 (Baltimore City Health Department, 2008). Baltimore Citys
percentage of adults who are obese is 35% which surpasses the Maryland average (Baltimore
City Health Department, 2008). In 1997 the U.S. rate for obese was 16.5, Maryland was 17.5
and Baltimore City was 23.5, in 2002 the rate for obesity was U.S. 21.9, Maryland 19.4, and
Baltimore City 24.0, in 2007 U.S. was 26.3, Maryland 26.3 and Baltimore City 35.0 (Baltimore
City Health Department, 2008). In Baltimore City the prevalence among adults increase by 50%
from 1997 to 2007 and that Baltimore City has about 30% higher obesity prevalence than in
Maryland and the national(Baltimore City Health Department, 2008). In Baltimore City nearly
twice as many black adults as white adults that were surveyed are report obese (Baltimore City
Health Department, 2008). Based on body mass index in 1997 38.3% of Baltimore city residents
were normal weight, 38.3 were overweight and 23.5 were obese (Baltimore City Health
Department, 2008). In 2007 these figures shifted as obesity become more of a health concern,
32.3% of Baltimore city residents are normal weight 32.7 % overweight and 35 % are
obese(Baltimore City Health Department, 2008).
Even though it is thought that socioeconomic status plays a role in higher obesity levels ,
obesity has drastically increased in all adults , at all incomes and education levels across the last
ten years. The biggest increase in obesity is black female. In Baltimore City 41.1% of females
are obese and 26.5% of males are obese according to sex (Baltimore City Health Department,
2008). In Baltimore City 23.3% of whites are obese and 43.5% of blacks are obese (Baltimore
City Health Department, 2008).

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Resources and agencies that have taken initiatives to fight obesity have so far been
unsuccessful. The obese rates continue to climb. First Lady Michele Obama has joined the fight
against obesity by launching a government program called Lets Move. Michele Obama has
traveled the country promoting this plan which is designed to get kids and families to eat
healthier and get more exercise, get evolved and take action. The program has had a large media
promotion and has its own website at www.letsmove.gov. Lets Move is a comprehensive
initiative that wants to help solve the problem of obesity by targeting the children and families of
this generation to give helpful information to support healthy lifestyle. The first lady wants to
provide healthy foods in our school, assess to healthy affordable foods to all families, and help
kids become more physically active.
According to Lets moves website, Americans led lives that kept them at a healthy
weight thirty years ago and today we are losing the battle with obesity. Thirty years ago kids
walked to school every day, ran around during recess, had gym class every day, and played for
hours after school outside. Families ate all meals at home with smaller portions and always a
vegetable on the plate. Today things are very different for families. Today children ride the bus
to school or are driven to school by their parents, gym classes have been cut to only a few times
a week if at all. Children do not play outside all afternoon until dinnertime. Most children spend
their afternoons playing video games, watching TV or on the computer. Families have fewer
home cooked meals and are eating fast food frequently. Part of the first ladys plan is to help the
families in underserved area by using the Eating on a Budget-The 3Ps which is plan, purchase
and prepare (Lets Move, n.d.). The first part of the 3Ps is to plan meals and snack for the whole
week. Based on a budget, including meals that will stretch such as stews, casseroles and stir-fried
dishes (Lets Move, n.d.). Make grocery lists based on what is on sale and coupons, considering
online coupons and discount stores and loyalty cards at grocery stores (Lets Move, n.d.). The

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purchase part of the 3Ps starts with shopping when you are not hungry or rushed, stick to your
list, buy store brands (Lets Move, n.d.). Try purchasing items in bulk or family packs. Choose
fresh fruits and vegetables that are in season, and if you have to buy canned vegetables buy those
with less salt (Lets Move, n.d.). Some good low cost items available all year round are beans,
carrots, greens, potatoes, apples and bananas (Lets Move, n.d.). Prepare some meals in advance
on days when you have extra time. Double your recipes and freeze a portion. Try some meatless
means substituting with beans. Use leftovers into subsequent meals, be creative (Lets Move,
n.d.).
Healthy People 2010 was a federal initiative that state and local health departments used
as a guide to set and achieve targets for their communities and states. The federal government
issues a new healthy people every ten years with new objectives based on what is needed for
national, state and local community. Healthy People had five goals focused on obesity. Goal 1
was to increase physical activity among children and adolescents; Goal 2 is to reduce the amount
of time kids watch TV, video games and the internet, Goal 3 was to decrease the consumption of
energy-dense, high sugar high fat foods like soda, ice cream, junk foods and fast foods, Goal #4
was increase the consumption of nutritious foods like fruits, vegetables, whole grains and skim
milk and goal#5 was to create social, monetary, and policy driven incentives that reinforce long
term environmental and behavioral changes(American Public Health Association, 2012, p. 3).
Based on a governmental report from US Department of Health and Human Services Healthy
people 2010 was very successful in all areas except health disparities and obesity.
Healthy People 2020 has changed and modified its objectives to fight obesity for the next
ten years. Over the next ten years they will work on Goal #1 healthier food access, Goal #2
healthcare and worksite settings, Goal #3 weight status, Goal# 4 food insecurity and Goal #5
food and nutrient consumption ("Healthy people 2020," 2012, p. 1). The federal and state

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governments want to meet goal 1 by increasing the number of states with nutrition standards for
food and beverages provided to preschool aged children in child care, increase the proportion of
schools that offer nutritious foods outside of school meals, increase the number of states that
have state level policies that incentivize food retail to provide foods that are encouraged by the
dietary guidelines for Americans and increase the number of Americans who have access to a
food outlet that sells a variety of food that are recommended by the dietary guidelines for
Americans ("Healthy people 2020," 2012, p. 1). Goal 2 objectives are to increase the number of
primary care physicians who measure their patients body mass index, increase the number of
physicians that include counseling and education related to weight in office visits and increase
the number of worksites that offer nutrition and weight management classes or counseling
onsite("Healthy people 2020," 2012, p. 1). Goal 3 objectives are to reduce the number of adults
who are obese, increase the number of adults who are a healthy weight, reduce the number of
children and adolescents who are obese, and prevent weight gain in youths and adults ("Healthy
people 2020," 2012, p. 1). Goal4 is to eliminate very low food security among children, and
reduce household food insecurity and reduce hunger. Goal 5 objectives is to increase the variety
and contributions of fruits, vegetable, whole grains, and reduce the consumption of saturated
fats, sodium, and increase the consumption of calcium ("Healthy people 2020," 2012, p. 1).
Healthy people 2020 has consumer resources at www.healthfinder.gov from the quick
guide to healthy living that offer quick tips by clicking on the topic link for the following topics:
healthy snacks, keeping your heart healthy, eat healthy, watch your weight, getting enough
calcium, take steps to prevent type 2 diabetes, shopping lists, low sodium foods, eating healthy
during pregnancy ("Healthy people 2020" 2012, p. 1). All of these topics are geared to help
Americans lower theirs calories and eat healthier to maintain a healthy weight. The information
is presented in a simple way that is eat to understand and easy to follow.

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The Maryland Department of Health and Mental Hygiene has partnered with University
of Maryland in Baltimore to establish the Institute for a Healthiest Maryland ("Healthiest
Maryland," 2012). Their mission is to improve the health of Maryland citizens, the Institute will
support community transformation efforts, translate public health research into practice, and
provide technical assistance to local health departments and community
organizations("Healthiest Maryland," 2012). The institute is a new resource for Maryland
communities across the state to improve wellness. The three areas the institute will focus on are
obesity prevention, tobacco prevention and management of hypertension ("Healthiest Maryland,"
2012).
The Institute for a Healthiest Maryland has aligned with the first ladys Lets Move
program and created five goals to promote healthy eating and active living on a local community
level (12). The first goal is start early, start smart, which is to provide children with a health start
to their day. Goal 2 is my plate, my place to empower parents and caregivers. Goal3 is smart
serving for students, trying to provide healthy foods in schools for breakfast and lunch programs.
Goal 4 is model food service to improve access to healthy affordable foods to all citizens. Goal
five is active kids at play which is to increase active, mapping local play places. The launch of
their website at www.healthiestmaryland.org has a lot of local resources for area programs in
place.
Where people live affects how they live. Families can play a very important role as
models, encouragers and facilitators of physical activity ("Barriers," 2012). Paternal activity
levels, positive rein enforcement, maternal participation, sibling involvement, time spent
outdoors, family income and safety are all important factors that contribute to healthy lifestyles
of families ("Barriers," 2012). Employed adults spend at least 25% of their lives at work and the
pressure and demands of their jobs may affect their eating habits and activity levels ("Barriers,"

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2012). If someone works in an adverse job condition they are more likely to be overweight or
obese ("Barriers," 2012). Some factors that contribute are high stress jobs, long hours,
decreased physical activity, and especially shift workers ("Barriers," 2012).
Baltimore City inner city neighborhoods dont have bike lanes and street designs to slow
traffic, safe to cross sidewalks, parks and gyms, shops in walking distance, of which all of these
nice features would make a difference in the ability for Baltimore city residents to have healthier
lifestyles ("Barriers," 2012). Not much research is available yet on the design of neighborhoods
and the connection to obesity. Low income and minority neighborhoods have zero to fewer
recreational facilities than wealthier white communities ("Barriers," 2012). Cost may play an
important role in that as low income residents may not have money to purchase gym
memberships and enroll their children in extracurricular sports.
Risks to safety are a major player in inner city obesity trends. There is evidence that in
inner city neighborhoods where people do not feel safe, children are less likely to play outside,
adults are less likely or wary to walk about or take part in outside activities ("Barriers," 2012).
Studies have shown that neighborhood with higher crime rates have higher rates of obesity
("Barriers," 2012).
The nurse practitioner must seek a weight history including previous attempts to
lose weight when assess for obesity, discuss willingness to make changes (Logue et al., 2010, p.
474). Advise patients of the long term health benefits of losing weight such as improved lipid
profiles, glycemic control, reduced blood pressure, lower risk of diabetes, lower mortality from
cancer, diabetes, lower osteoarthritis disability, and improved lung function in asthma (Logue et
al., 2010, p. 474).

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Treatment targets are based on co morbidities and risk rather than weight all by itself
(Logue et al., 2010, p. 474). Patients with a BMI over 35 will need to lose 15-20%, over 10kg,
of their weight for sustained improvements of co morbidities (Logue et al., 2010, p. 474).
Patients with a BMI of 25-35% will need to lose 5-10%, 5-10kg, of weight in order to reduce risk
of cardiovascular and metabolic disease (Logue et al., 2010, p. 475). Patients from certain ethnic
group are more susceptible to the metabolic effects of obesity and co morbidities at a lower BMI
and need cut off points tailored to individual needs (Logue et al., 2010, p. 475). Treatment for
obesity encompasses weight management programs, dietary interventions, physical activities,
behavioral interventions, pharmacotherapy and lastly bariatric surgery.
Weight management programs can be successful if the patient is willing to make changes.
These programs should include dietary changes, physical activity and a behavioral component
(Logue et al., 2010, p. 475). Many medical personnel suggest commercial weight loss programs
such as weight watchers or programs on the internet as part of many healthy options. Calculate
dietary interventions to produce a 600 kcal energy deficit each day will produce weight loss
(Logue et al., 2010, p. 475). When discussing dietary changes make sure to emphasize
achievable and sustainable healthy eating. Give patients lists of foods that are healthy to eat and
portions sizes. Also give patients lists of foods to avoid like high fatty foods, animal fats, sugary
foods and drinks. Patients should limit alcohol consumptions and totally eliminate fast foods.
Patients should increase the amounts of whole grains, fruits, vegetables.
Physical activity will play a major role in losing weight. According to Moyer, a
prescribed volume of physical activity of 1800-2500kcal a week that corresponds to 225-300
minutes a week of moderate physical activity is needed to lose weight (Logue et al., 2010, p.
475). This can be broken down into many ways and an example would be five sessions of 45-50
minutes a week. Moderately intense physical activity should increase the rate of breathing and

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10

body temperature but still enable the person to conversation comfortably (Logue et al., 2010, p.
475). For obese people brisk walking is a good physical activity. Patient many break up their
physical activity throughout their day to make it more manageable, small sessions of at least 10
minutes in duration. Patients that are sedentary can build up their physical activity levels over
time.
Every plan that is put in place must be tailored for the individual and their unique
circumstances. Psychological and behavioral interventions should use situational control
including avoidance of cues to unhealthy eating. Self-monitoring of food intake by writing a
food journal can help a patient realize what calorie the patient actually consumes (Logue et al.,
2010, p. 475). Goal setting that includes relapse prevention stragies is key and cognitive stragies
to replace negative thinking with positive thinking (Logue et al., 2010, p. 475).
Pharmacologic therapy can be tried after attempts of weight loss using behavior
medication, dietary restrictions and increased physical activity have failed. Pharmacologic
therapy must be used with a comprehensive weight loss program. A commonly used drug is
Orlistat which is a pancreatic lipase inhibitor that works in the gut to prevent the absorption of at
least 30% of fat intake. This medication has many side effects such as flatus, oily spotting,
abdominal pain and fecal incontinence. Sibutramine is another weight loss medication that acts
on the brain to suppress appetite. Side effects are dry mouth, insomnia, headache, constipation
and restlessness.
Bariatric surgery can be considered when all other weight loss efforts
have failed. Bariatric surgery may be an option for patients that meet the
following criteria: BMI of 35 or greater, one or more severe co morbidities
that are expected to have a meaningful clinical improvement with weight
reduction and evidence of completion of a structured weight program that

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11

covered diet, physical activity, and psychological and drug interventions but
did not result in significant improvement (Logue et al., 2010, p. 475). There
are three types of bariatric procedures currently preformed in the US. today.
First is the adjustable gastric banding which involves inserting an inflatable
ring, usually laparoscopically, which can be adjusted via a subcutaneous
access point (Schroeder, Garrison, & Johnson, 2011, p. 809). Second is a
laparoscopic sleeve gastrostomy, that is a non-reversible procedure where
most of the body of the stomach (Schroeder, Garrison, & Johnson, 2011, p.
809). The remaining portion of the stomach is formed into a narrow tube or
sleeve and the pylorus is preserved (Schroeder, Garrison, & Johnson, 2011, p.
809).
In Conclusion Baltimore City resident are slightly more obese than the
state average and even though several federal programs are in place,
Baltimore city does have very many local programs in place to help our inner
city residents. Baltimore City residents face many barriers to living a healthy
lifestyle with not much support from the government or the medical
profession.

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12
References

Action plan: healthy people 2010 objectives for prevention and control of
childhood obesity. American Public Health Association. Retrieved from
http://www.apha.org/programs/resources/obesity/obesityaction
plan.htm
Baltimore City Health Department. (2008, July 23). Fact sheet: overweight
and obesity in Baltimore City, 1997-2007 [fact sheet]. Retrieved from
Baltimore City Health Department: http://baltimorehealth.org
Center for Disease Control. (n.d.). http://www.cdc.gov/obesity/data/adult.html
Five goal align with lets move. (2012). Retrieved from
www.healthiestmaryland.org
Healthy people 2020. (2012). Retrieved from http://www.healthypeople.gov
Lets Move. (n.d.). http://www.letsmove.gov
Logue, J., Thompson, L., Romances, F., Wilson, D., Thompson, J., & Sattar, N.
(2010, February 27). Management of obesity: summary of sign
guideline. Annals of Internal Medicine, 157(5), 474-478.
doi:10.1136/bmj.c154
McCance, K., Huether, S., Brashers, V., & Rote, N. (2010). Pathophysiology
the Biologic Basis for Disease in Adults and Children (6th ed.).
Schroeder, R., Garrison, J., & Johnson, M. (2011, October 1). Treatment of
adult obesity with bariatric surgery. American Academy of Family
Physicians, 84(7), 805-814. Retrieved from www.aafp.org/afp
The obesity prevention source. (2012). Retrieved from
www.hsph.harvard.edu