Social Determinants of Obesity: Treating Urban & Rural Patients

Obesity is a complicated disease resulting from interlocking causes that vary with each patient. A person’s upbringing, culture, access to information and optimal nutrition (or lack thereof), psychosocial profile, exposure to pollution and stress, and a wide variety of other factors affect whatever genetic substrate is present to promote obesity.

Image courtesy of Obesity Canada Image Bank

As health care providers (HCPs), it is important that we get to know an individual as a whole person, including external factors and social determinants of health. Patients in urban and rural settings offer unique challenges that should be considered when tailoring personalized care plans for chronic obesity management.

Obesity Medicine in Urban Areas

Both the built and social environment should be considered for obesity medicine in urban areas.

A patient’s built environment—including structures, parking lots, green or recreational spaces, waste areas, and nearby operating businesses—can have an obesogenic effect. For example, if a neighborhood lacks grocery stores, but has many convenience stores that typically offer energy-dense, highly processed, nutrient-poor food, local residents may be less likely to maintain healthy eating patterns. Additionally, air pollution in a given neighborhood may further discourage physical activity or even contribute to obesity itself.

The social environment also plays a vital role in promoting or inhibiting obesity treatment. In urban settings, many challenges to obesity treatment are mediated through stress, especially in under-resourced areas.

The poverty level, amount of violence, and visible disorder of a patient’s neighborhood can increase stress, and are associated with a rise in behavioral triggers impacting nutritional choices, decreased physical activity, and higher rates of obesity. In other words, the social environments of disadvantaged urban areas provide greater obstacles and fewer resources for patients with obesity. Participating in an open conversation about these factors will help HCPs create realistic care plans and optimize available resources for patients.

Obesity Management in Rural Areas

Individuals in rural communities face numerous major health challenges related to obesity. According to a 2018 CDC report, obesity prevalence was significantly higher among adults living in rural counties (34.2%) compared with those living in metropolitan counties (28.7%). Rural America is characterized by very low population density, older populations, higher rates of poverty, and fewer transportation options.¹ Many rural communities also lack access to healthy, affordable food.

In addition to social determinants, HCPs should consider available resources when creating obesity treatment plans for rural patients. Rural health care facilities frequently do not have nutritionists, dietitians, or obesity medicine specialists to help patients with obesity attain better health.

Many people in these communities are also uninsured or underinsured and would have to pay for treatment out of pocket. What’s more, the distance, expense, and lack of transportation for accessing health care facilities, exercise facilities, and healthy food can hinder health outcomes.

Regardless of the conditions of a patient’s living environment, consider the following when approaching the topic of weight and weight management:

• Meet patients where they are. Avoid overwhelming them with too many expectations.
• Set realistic goals. Consider the patient’s built and social environments.
• Follow up frequently. Continue to advance and adjust your treatment program step by step when possible.
• Remember likely barriers. If you start to feel an individual is not implementing the care plan created using shared decision-making, consider obstacles related to social determinants of health.
• Ask permission to discuss obesity. This starts the conversation with respect for the patient’s agency and emotional readiness.
• Respect the patient’s answer. If the response is no, offer resources and let the patient know that the door is always open for a discussion.
• Emphasize that obesity is a disease, not a character flaw. If the patient is open to having a conversation, educate them about the disease of obesity and its health consequences, and underline that obesity is a medical disease, not a moral failing.
• Convey hope and encouragement. People with obesity have often struggled with the disease on their own for many years. It is important to reassure them that small changes can really reduce the risk of bad outcomes.
• Brainstorm possible plans. Explore the variety of treatment options together.

Resources from the Obesity Medicine Association (OMA) are critical in keeping urban and rural medical professionals updated on the latest developments in obesity medicine. Become a member today and continue your education advancement in this field by joining OMA’s fall conference where we will focus on how to treat obesity across the lifespan.

Reference: Rose V, Warrington V. Treating obesity in socioeconomically disadvantaged communities. Paper presented at: Obesity Medicine Association Fall 2020 Conference; October 2020; virtual.

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 OMA. Ingersoll 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 is also founder of the PAs in Obesity Medicine special interest group and founder of the Arizona Obesity Organization.

Wickham Simonds, MD, FOMA, is the founder of Dr Simonds Metabolics & Weight Loss and currently practices obesity medicine with offices in Durham and Raleigh. Dr Simonds is board-certified by the American Board of Emergency Medicine and is a diplomate of the American Board of Obesity Medicine. He was chief resident during his residency in emergency medicine at Penn State University/York Hospital. Dr Simonds received his MD from East Carolina University and his BS in biology from Campbell University. He received the Dr Raymond E. Dietz Meritorious Service Award from OMA in 2017. He has served his country in the US Army with duty stations in Korea, Louisiana, and Iraq.