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Obesity research: Moving from bench to bedside to population

* E-mail: [email protected]

Affiliation Diabetes Research Program, Department of Medicine, New York University Grossman School of Medicine, New York, New York, United States of America

• Ann Marie Schmidt

Published: December 4, 2023

• https://doi.org/10.1371/journal.pbio.3002448
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Globally, obesity is on the rise. Research over the past 20 years has highlighted the far-reaching multisystem complications of obesity, but a better understanding of its complex pathogenesis is needed to identify safe and lasting solutions.

Citation: Schmidt AM (2023) Obesity research: Moving from bench to bedside to population. PLoS Biol 21(12): e3002448. https://doi.org/10.1371/journal.pbio.3002448

Copyright: © 2023 Ann Marie Schmidt. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: AMS received funding from U.S. Public Health Service (grants 2P01HL131481 and P01HL146367). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The author has declared that no competing interests exist.

Abbreviations: EDC, endocrine disruptor chemical; GIP, gastric inhibitory polypeptide; GLP1, glucagon-like peptide 1; HFCS, high-fructose corn syrup

This article is part of the PLOS Biology 20th anniversary collection.

Obesity is a multifaceted disorder, affecting individuals across their life span, with increased prevalence in persons from underrepresented groups. The complexity of obesity is underscored by the multiple hypotheses proposed to pinpoint its seminal mechanisms, such as the “energy balance” hypothesis and the “carbohydrate–insulin” model. It is generally accepted that host (including genetic factors)–environment interactions have critical roles in this disease. The recently framed “fructose survival hypothesis” proposes that high-fructose corn syrup (HFCS), through reduction in the cellular content of ATP, stimulates glycolysis and reduces mitochondrial oxidative phosphorylation, processes that stimulate hunger, foraging, weight gain, and fat accumulation [ 1 ]. The marked upswing in the use of HFCS in beverages and foods, beginning in the 1980s, has coincided with the rising prevalence of obesity.

The past few decades of scientific progress have dramatically transformed our understanding of pathogenic mechanisms of obesity ( Fig 1 ). Fundamental roles for inflammation were unveiled by the discovery that tumor necrosis factor-α contributed to insulin resistance and the risk for type 2 diabetes in obesity [ 2 ]. Recent work has ascribed contributory roles for multiple immune cell types, such as monocytes/macrophages, neutrophils, T cells, B cells, dendritic cells, and mast cells, in disturbances in glucose and insulin homeostasis in obesity. In the central nervous system, microglia and their interactions with hypothalamic neurons affect food intake, energy expenditure, and insulin sensitivity. In addition to cell-specific contributions of central and peripheral immune cells in obesity, roles for interorgan communication have been described. Extracellular vesicles emitted from immune cells and from adipocytes, as examples, are potent transmitters of obesogenic species that transfer diverse cargo, including microRNAs, proteins, metabolites, lipids, and organelles (such as mitochondria) to distant organs, affecting functions such as insulin sensitivity and, strikingly, cognition, through connections to the brain [ 3 ].

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Basic, clinical/translational, and epidemiological research has made great strides in the past few decades in uncovering novel components of cell-intrinsic, intercellular, and interorgan communications that contribute to the pathogenesis of obesity. Both endogenous and exogenous (environmental) stressors contribute to the myriad of metabolic perturbations that impact energy intake and expenditure; mediate innate disturbances in the multiple cell types affected in obesity in metabolic organelles and organs, including in immune cells; and impair beneficial interkingdom interactions of the mammalian host with the gut microbiome. The past few decades have also witnessed remarkable efforts to successfully treat obesity, such as the use of the incretin agonists and bariatric surgery. Yet, these and other strategies may be accompanied by resistance to weight loss, weight regain, adverse effects of interventions, and the challenges of lifelong implementation. Hence, through leveraging novel discoveries from the bench to the bedside to the population, additional strategies to prevent obesity and weight regain post-weight loss, such as the use of “wearables,” with potential for implementation of immediate and personalized behavior modifications, may hold great promise as complementary strategies to prevent and identify lasting treatments for obesity. Figure created with BioRender.

https://doi.org/10.1371/journal.pbio.3002448.g001

Beyond intercellular communication mediated by extracellular vesicles, the discovery of interactions between the host and the gut microbiome has suggested important roles for this interkingdom axis in obesity. Although disturbances in commensal gut microbiota species and their causal links to obesity are still debated, transplantation studies have demonstrated relationships between Firmicutes/Bacteroidetes ratios and obesity [ 4 ]. Evidence supports the concept that modulation of gut microbiota phyla modulates fundamental activities, such as thermogenesis and bile acid and lipid metabolism. Furthermore, compelling discoveries during the past few decades have illustrated specific mechanisms within adipocytes that exert profound effects on organismal homeostasis, such as adipose creatine metabolism, transforming growth factor/SMAD signaling, fibrosis [ 5 ], hypoxia and angiogenesis, mitochondrial dysfunction, cellular senescence, impairments in autophagy, and modulation of the circadian rhythm. Collectively, these recent discoveries set the stage for the identification of potential new therapeutic approaches in obesity.

Although the above discoveries focus largely on perturbations in energy metabolism (energy intake and expenditure) as drivers of obesity, a recently published study suggests that revisiting the timeline of obesogenic forces in 20th and 21st century society may be required. The authors tracked 320,962 Danish schoolchildren (born during 1930 to 1976) and 205,153 Danish male military conscripts (born during 1939 to 1959). Although the overall trend of the percentiles of the distributions of body mass index were linear across the years of birth, with percentiles below the 75th being nearly stable, those above the 75th percentile demonstrated a steadily steeper rise the more extreme the percentile; this was noted in the schoolchildren and the military conscripts [ 6 ]. The authors concluded that the emergence of the obesity epidemic might have preceded the appearance of the factors typically ascribed to mediating the obesogenic transformation of society by several decades. What are these underlying factors and their yet-to-be-discovered mechanisms?

First, in terms of endogenous factors relevant to individuals, stressors such as insufficient sleep and psychosocial stress may impact substrate metabolism, circulating appetite hormones, hunger, satiety, and weight gain [ 7 ]. Reduced access to healthy foods rich in vegetables and fruits but easy access to ultraprocessed ingredients in “food deserts” and “food swamps” caused excessive caloric intake and weight gain in clinical studies [ 8 ]. Second, exogenous environmental stresses have been associated with obesity. For example, air pollution has been directly linked to adipose tissue dysfunction [ 9 ], and ubiquitous endocrine disruptor chemicals (EDCs) such as bisphenols and phthalates (found in many items of daily life including plastics, food, clothing, cosmetics, and paper) are linked to metabolic dysfunction and the development of obesity [ 10 ]. Hence, factors specific to individuals and their environment may exacerbate their predisposition to obesity.

In addition to the effects of exposure to endogenous and exogenous stressors on the risk of obesity, transgenerational (passed through generations without direct exposure of stimulant) and intergenerational (direct exposure across generations) transmission of these stressors has also been demonstrated. A leading proposed mechanism is through epigenetic modulation of the genome, which then predisposes affected offspring to exacerbated responses to obesogenic conditions such as diet. A recent study suggested that transmission of disease risk might be mediated through transfer of maternal oocyte-derived dysfunctional mitochondria from mothers with obesity [ 11 ]. Additional mechanisms imparting obesogenic “memory” may be evoked through “trained immunity.”

Strikingly, the work of the past few decades has resulted in profound triumphs in the treatment of obesity. Multiple approved glucagon-like peptide 1 (GLP1) and gastric inhibitory polypeptide (GIP) agonists [ 12 ] (alone or in combinations) induce highly significant weight loss in persons with obesity [ 13 ]. However, adverse effects of these agents, such as pancreatitis and biliary disorders, have been reported [ 14 ]. Therefore, the long-term safety and tolerability of these drugs is yet to be determined. In addition to pharmacological agents, bariatric surgery has led to significant weight loss as well. However, efforts to induce weight loss through reduction in caloric intake and increased physical activity, pharmacological approaches, and bariatric surgery may not mediate long-term cures in obesity on account of resistance to weight loss, weight regain, adverse effects of interventions, and the challenges of lifelong implementation of these measures.

Where might efforts in combating obesity lie in the next decades? At the level of basic and translational science, the heterogeneity of metabolic organs could be uncovered through state-of-the-art spatial “omics” and single-cell RNA sequencing approaches. For example, analogous to the deepening understanding of the great diversity in immune cell subsets in homeostasis and disease, adipocyte heterogeneity has also been suggested, which may reflect nuances in pathogenesis and treatment approaches. Further, approaches to bolster brown fat and thermogenesis may offer promise to combat evolutionary forces to hoard and store fat. A better understanding of which interorgan communications may drive obesity will require intensive profiling of extracellular vesicles shed from multiple metabolic organs to identify their cargo and, critically, their destinations. In the three-dimensional space, the generation of organs-on-a-chip may facilitate the discovery of intermetabolic organ communications and their perturbations in the pathogenesis of obesity and the screening of new therapies.

Looking to prevention, recent epidemiological studies suggest that efforts to tackle obesity require intervention at multiple levels. The institution of public health policies to reduce air pollution and the vast employment of EDCs in common household products could impact the obesity epidemic. Where possible, the availability of fresh, healthy foods in lieu of highly processed foods may be of benefit. At the individual level, focused attention on day-to-day behaviors may yield long-term benefit in stemming the tide of obesity. “Wearable” devices that continuously monitor the quantity, timing, and patterns of food intake, physical activity, sleep duration and quality, and glycemic variability might stimulate on-the-spot and personalized behavior modulation to contribute to the prevention of obesity or of maintenance of the weight-reduced state.

Given the involvement of experts with wide-ranging expertise in the science of obesity, from basic science, through clinical/translational research to epidemiology and public health, it is reasonable to anticipate that the work of the next 2 decades will integrate burgeoning multidisciplinary discoveries to drive improved efforts to treat and prevent obesity.

Acknowledgments

The author is grateful to Ms. Latoya Woods of the Diabetes Research Program for assistance with the preparation of the manuscript and to Ms. Kristen Dancel-Manning for preparation of the Figure accompanying the manuscript.

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A systematic literature review on obesity: Understanding the causes & consequences of obesity and reviewing various machine learning approaches used to predict obesity

Affiliations.

• 1 Centre for Software Technology and Management, Faculty of Information Science and Technology, Universiti Kebangsaan Malaysia (UKM), Bangi, 43600, Selangor, Malaysia.
• 2 Centre for Software Technology and Management, Faculty of Information Science and Technology, Universiti Kebangsaan Malaysia (UKM), Bangi, 43600, Selangor, Malaysia. Electronic address: [email protected].
• 3 RIADI Laboratory, University of Manouba, Manouba, Tunisia; College of Computer Science and Engineering, Taibah University, Medina, Saudi Arabia.
• 4 Center for Artificial Intelligence Technology, Faculty of Information Science and Technology, Universiti Kebangsaan Malaysia (UKM), Bangi, 43600, Selangor, Malaysia.
• PMID: 34426171
• DOI: 10.1016/j.compbiomed.2021.104754

Obesity is considered a principal public health concern and ranked as the fifth foremost reason for death globally. Overweight and obesity are one of the main lifestyle illnesses that leads to further health concerns and contributes to numerous chronic diseases, including cancers, diabetes, metabolic syndrome, and cardiovascular diseases. The World Health Organization also predicted that 30% of death in the world will be initiated with lifestyle diseases in 2030 and can be stopped through the suitable identification and addressing of associated risk factors and behavioral involvement policies. Thus, detecting and diagnosing obesity as early as possible is crucial. Therefore, the machine learning approach is a promising solution to early predictions of obesity and the risk of overweight because it can offer quick, immediate, and accurate identification of risk factors and condition likelihoods. The present study conducted a systematic literature review to examine obesity research and machine learning techniques for the prevention and treatment of obesity from 2010 to 2020. Accordingly, 93 papers are identified from the review articles as primary studies from an initial pool of over 700 papers addressing obesity. Consequently, this study initially recognized the significant potential factors that influence and cause adult obesity. Next, the main diseases and health consequences of obesity and overweight are investigated. Ultimately, this study recognized the machine learning methods that can be used for the prediction of obesity. Finally, this study seeks to support decision-makers looking to understand the impact of obesity on health in the general population and identify outcomes that can be used to guide health authorities and public health to further mitigate threats and effectively guide obese people globally.

Keywords: Diseases; Machine learning; Obesity; Overweight; Risk factors.

Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.

Publication types

• Research Support, Non-U.S. Gov't
• Systematic Review
• Machine Learning
• Metabolic Syndrome*
• Obesity* / epidemiology
• Risk Factors

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NIH-Supported Obesity Research

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The Strategic Plan for NIH Obesity Research serves as a guide to accelerate a broad spectrum of research toward developing new and more effective approaches to address the tremendous burden of obesity, so that people can look forward to healthier lives.

The Plan was originally published in 2011. In 2018-2019, the Obesity Research Task Force confirmed that the challenges and opportunities identified in the Plan reflect the current research landscape and should continue to guide obesity research.

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Obesity Research

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Over the years, NHLBI-supported research on overweight and obesity has led to the development of evidence-based prevention and treatment guidelines for healthcare providers. NHLBI research has also led to guidance on how to choose a behavioral weight loss program.

Studies show that the skills learned and support offered by these programs can help most people make the necessary lifestyle changes for weight loss and reduce their risk of serious health conditions such as heart disease and diabetes.

Our research has also evaluated new community-based programs for various demographics, addressing the health disparities in overweight and obesity.

NHLBI research that really made a difference

• In 1991, the NHLBI developed an Obesity Education Initiative to educate the public and health professionals about obesity as an independent risk factor for cardiovascular disease and its relationship to other risk factors, such as high blood pressure and high blood cholesterol. The initiative led to the development of clinical guidelines for treating overweight and obesity.
• The NHLBI and other NIH Institutes funded the Obesity-Related Behavioral Intervention Trials (ORBIT) projects , which led to the ORBIT model for developing behavioral treatments to prevent or manage chronic diseases. These studies included families and a variety of demographic groups. A key finding from one study focuses on the importance of targeting psychological factors in obesity treatment.

Current research funded by the NHLBI

The Division of Cardiovascular Sciences , which includes the Clinical Applications and Prevention Branch, funds research to understand how obesity relates to heart disease. The Center for Translation Research and Implementation Science supports the translation and implementation of research, including obesity research, into clinical practice. The Division of Lung Diseases and its National Center on Sleep Disorders Research fund research on the impact of obesity on sleep-disordered breathing.

Find funding opportunities and program contacts for research related to obesity and its complications.

Current research on obesity and health disparities

Health disparities happen when members of a group experience negative impacts on their health because of where they live, their racial or ethnic background, how much money they make, or how much education they received. NHLBI-supported research aims to discover the factors that contribute to health disparities and test ways to eliminate them.

• NHLBI-funded researchers behind the RURAL: Risk Underlying Rural Areas Longitudinal Cohort Study want to discover why people in poor rural communities in the South have shorter, unhealthier lives on average. The study includes 4,000 diverse participants (ages 35–64 years, 50% women, 44% whites, 45% Blacks, 10% Hispanic) from 10 of the poorest rural counties in Kentucky, Alabama, Mississippi, and Louisiana. Their results will support future interventions and disease prevention efforts.
• The Hispanic Community Health Study/Study of Latinos (HCHS/SOL) is looking at what factors contribute to the higher-than-expected numbers of Hispanics/Latinos who suffer from metabolic diseases such as obesity and diabetes. The study includes more than 16,000 Hispanic/Latino adults across the nation.

Find more NHLBI-funded studies on obesity and health disparities at NIH RePORTER.

Read how African Americans are learning to transform soul food into healthy, delicious meals to prevent cardiovascular disease: Vegan soul food: Will it help fight heart disease, obesity?

Current research on obesity in pregnancy and childhood

• The NHLBI-supported Fragile Families Cardiovascular Health Follow-Up Study continues a study that began in 2000 with 5,000 American children born in large cities. The cohort was racially and ethnically diverse, with approximately 40% of the children living in poverty. Researchers collected socioeconomic, demographic, neighborhood, genetic, and developmental data from the participants. In this next phase, researchers will continue to collect similar data from the participants, who are now young adults.
• The NHLBI is supporting national adoption of the Bright Bodies program through Dissemination and Implementation of the Bright Bodies Intervention for Childhood Obesity . Bright Bodies is a high-intensity, family-based intervention for childhood obesity. In 2017, a U.S. Preventive Services Task Force found that Bright Bodies lowered children’s body mass index (BMI) more than other interventions did.
• The NHLBI supports the continuation of the nuMoM2b Heart Health Study , which has followed a diverse cohort of 4,475 women during their first pregnancy. The women provided data and specimens for up to 7 years after the birth of their children. Researchers are now conducting a follow-up study on the relationship between problems during pregnancy and future cardiovascular disease. Women who are pregnant and have obesity are at greater risk than other pregnant women for health problems that can affect mother and baby during pregnancy, at birth, and later in life.

Find more NHLBI-funded studies on obesity in pregnancy and childhood at NIH RePORTER.

Learn about the largest public health nonprofit for Black and African American women and girls in the United States: Empowering Women to Get Healthy, One Step at a Time .

Current research on obesity and sleep

• An NHLBI-funded study is looking at whether energy balance and obesity affect sleep in the same way that a lack of good-quality sleep affects obesity. The researchers are recruiting equal numbers of men and women to include sex differences in their study of how obesity affects sleep quality and circadian rhythms.
• NHLBI-funded researchers are studying metabolism and obstructive sleep apnea . Many people with obesity have sleep apnea. The researchers will look at the measurable metabolic changes in participants from a previous study. These participants were randomized to one of three treatments for sleep apnea: weight loss alone, positive airway pressure (PAP) alone, or combined weight loss and PAP. Researchers hope that the results of the study will allow a more personalized approach to diagnosing and treating sleep apnea.
• The NHLBI-funded Lipidomics Biomarkers Link Sleep Restriction to Adiposity Phenotype, Diabetes, and Cardiovascular Risk study explores the relationship between disrupted sleep patterns and diabetes. It uses data from the long-running Multiethnic Cohort Study, which has recruited more than 210,000 participants from five ethnic groups. Researchers are searching for a cellular-level change that can be measured and can predict the onset of diabetes in people who are chronically sleep deprived. Obesity is a common symptom that people with sleep issues have during the onset of diabetes.

Find more NHLBI-funded studies on obesity and sleep at NIH RePORTER.

Learn about a recent study that supports the need for healthy sleep habits from birth: Study finds link between sleep habits and weight gain in newborns .

Obesity research labs at the NHLBI

The Cardiovascular Branch and its Laboratory of Inflammation and Cardiometabolic Diseases conducts studies to understand the links between inflammation, atherosclerosis, and metabolic diseases.

NHLBI’s Division of Intramural Research , including its Laboratory of Obesity and Aging Research , seeks to understand how obesity induces metabolic disorders. The lab studies the “obesity-aging” paradox: how the average American gains more weight as they get older, even when food intake decreases.

Related obesity programs and guidelines

• Aim for a Healthy Weight is a self-guided weight-loss program led by the NHLBI that is based on the psychology of change. It includes tested strategies for eating right and moving more.
• The NHLBI developed the We Can! ® (Ways to Enhance Children’s Activity & Nutrition) program to help support parents in developing healthy habits for their children.
• The Accumulating Data to Optimally Predict obesity Treatment (ADOPT) Core Measures Project standardizes data collected from the various studies of obesity treatments so the data can be analyzed together. The bigger the dataset, the more confidence can be placed in the conclusions. The main goal of this project is to understand the individual differences between people who experience the same treatment.
• The NHLBI Director co-chairs the NIH Nutrition Research Task Force, which guided the development of the first NIH-wide strategic plan for nutrition research being conducted over the next 10 years. See the 2020–2030 Strategic Plan for NIH Nutrition Research .
• The NHLBI is an active member of the National Collaborative on Childhood Obesity (NCCOR) , which is a public–private partnership to accelerate progress in reducing childhood obesity.
• The NHLBI has been providing guidance to physicians on the diagnosis, prevention, and treatment of obesity since 1977. In 2017, the NHLBI convened a panel of experts to take on some of the pressing questions facing the obesity research community. See their responses: Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents (PDF, 3.69 MB).
• In 2021, the NHLBI held a Long Non-coding (lnc) RNAs Symposium to discuss research opportunities on lnc RNAs, which appear to play a role in the development of metabolic diseases such as obesity.
• The Muscatine Heart Study began enrolling children in 1970. By 1981, more than 11,000 students from Muscatine, Iowa, had taken surveys twice a year. The study is the longest-running study of cardiovascular risk factors in children in the United States. Today, many of the earliest participants and their children are still involved in the study, which has already shown that early habits affect cardiovascular health later in life.
• The Jackson Heart Study is a unique partnership of the NHLBI, three colleges and universities, and the Jackson, Miss., community. Its mission is to discover what factors contribute to the high prevalence of cardiovascular disease among African Americans. Researchers aim to test new approaches for reducing this health disparity. The study incudes more than 5,000 individuals. Among the study’s findings to date is a gene variant in African Americans that doubles the risk of heart disease.

Explore more NHLBI research on overweight and obesity

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Bridging the Evidence Gap in Obesity Prevention: A Framework to Inform Decision Making (2010)

Chapter: 10 conclusions and recommendations, 10 conclusions and recommendations.

D ecisions about prevention are complex, not only for the obesity problem but also for other problems with multiple types and layers of causation. Recognition of the need to emphasize population-based approaches to obesity prevention, the urgency of taking action, and the desire of many decision makers to have evidence on which actions to take have created a demand for evidence with which to answer a range of questions. In reality, the evidence approaches that apply to decision making about the treatment of obesity or other clinical problems are inadequate and sometimes inappropriate for application to decisions about public health initiatives. The need to work around evidence gaps and the limitations of using evidence hierarchies that apply to medical treatment for assessing population-based preventive interventions have been faced by the developers of several prior Institute of Medicine (IOM) reports on obesity prevention (focused on child and adolescent obesity). These evidence issues are not new and have already been the focus of many efforts in the field of public health in relation to other complex health problems. However, they are far from resolved. Considering these issues in relation to obesity prevention has the potential to advance the field of public health generally while also meeting the immediate need for clarity on evidence issues related to addressing the obesity epidemic.

The IOM’s Food and Nutrition Board formed the Committee on an Evidence Framework for Obesity Prevention Decision Making, with funding from Kaiser Permanente, the Robert Wood Johnson Foundation, and the Centers for Disease Control and Prevention. This committee was asked to develop a framework for evidence-informed decision making in obesity prevention, focused on approaches for assessing policy, environmental, and community interventions designed to influence diet and physical activity. The committee was tasked to:

provide an overview of the nature of the evidence base for obesity prevention as it is currently construed;

identify the challenges associated with integrating scientific evidence with broader influences on policy and programmatic considerations;

provide a practical and action-oriented framework of recommendations for how to select, implement, and evaluate obesity prevention efforts;

identify ways in which existing or new tools and methods can be used to build a useful and timely evidence base appropriate to the challenges presented by the epidemic, and describe ongoing attempts to meet these challenges;

develop a plan for communicating and disseminating the proposed framework and its recommendations; and

specify a plan for evaluating and refining the proposed framework in current decision-making processes.

CONCLUSIONS

Recognition is increasing that overweight and obesity are not only problems of individuals, but also societywide problems of populations. Acting on this recognition will require multifaceted, population-based changes in the socioenvironmental variables that influence energy intake and expenditure. There exist both a pressing need to act on the problem of obesity and a large gap between the type and amount of evidence needed to act and the type and amount of evidence available to meet that need. A new framework is necessary to assist researchers and a broad community of decision makers in generating, identifying, and evaluating the best evidence available and in summarizing it for use in decision making. This new framework also is important for researchers attempting to fill important evidence gaps through studies based on questions with program and policy relevance. However, the methods used and the evidence generated by traditional research designs do not yield all the types of evidence useful to inform actions aimed at addressing obesity prevention and other complex public health challenges. An expanded approach is needed that emphasizes the decision-making process and contextual considerations.

The Framework

To meet this need, the committee developed the L.E.A.D. ( L ocate Evidence, E valuate Evidence, A ssemble Evidence, and Inform D ecisions) framework, designed to facilitate a systematic approach to the identification, implementation, and evaluation of promising, reasonable actions to address obesity prevention and other complex public health challenges (see Figure 10-1 ). The framework is designed to help identify the nature of the evidence that is needed and clarify what changes in current approaches to generating and evaluating evidence will facilitate meeting those needs. This section describes the main components of the framework and issues related to these components.

Obesity prevention has not been addressed successfully by traditional study designs, which are generally linear and static. A systems approach is needed to develop more complex, interdisciplinary strategies. Accordingly, the L.E.A.D. framework

FIGURE 10-1 The L ocate Evidence, E valuate Evidence, A ssemble Evidence, Inform D ecisions (L.E.A.D.) framework for obesity prevention decision making.

recommends taking a systems perspective. In other words, it is necessary to use an approach that encompasses the whole picture, highlighting the broader context and interactions among levels, to capture the complexity of obesity prevention and other multifactorial public health challenges.

Addressing such challenges first requires specifying the question(s) being asked to guide the identification of evidence that is appropriate, inclusive, and relevant. Core to the framework is the orientation of the user. A variety of decisions have to be made to address obesity prevention. To capture the resulting mix of evidence needs, the framework adopts a typology that differentiates three broad categories of interrelated questions of potential interest to the user: Why should we do something about this problem? What specifically should we do? and How do we implement this information for our situation? This “Why,” “What,” “How” typology stresses the need for multiple types of evidence to support decisions on obesity prevention.

Once the question(s) of interest have been specified, locating useful evidence requires clear knowledge of the types of information that may be useful and an awareness of where that information can be found. The framework calls for the use of

diverse approaches to gather and synthesize information from other disciplines that address issues similar to those faced in obesity prevention and public health generally. Evidence identified and gathered to inform decision making for obesity prevention and other complex public health challenges should be assessed based on both its generalizability and level of certainty (i.e., its external and internal validity, respectively). The L.E.A.D. framework addresses these two key aspects of the evidence through the nature of the question(s) being asked, established criteria for the value of evidence, and the context in which the question(s) arise. Results of the overall evaluation of evidence should provide answers on what to do, how to do it, and how strongly the action is justified.

When decision makers are coming to a decision on obesity prevention actions, it is important for them to understand the state of the available knowledge relevant to that decision. This knowledge includes evidence on the specific problem to be addressed, the likely effectiveness and impact of proposed actions, and key considerations involved in their implementation. Successful evidence gathering, evaluation, and synthesis for use in obesity prevention usually require the involvement of a number of disciplines using a variety of methodologies and technical languages. The framework incorporates a standardized approach using a uniform language and structure for summarizing the relevant evidence in a systematic, transparent, and transdisciplinary way that is critical for communicating the process and conclusions clearly.

With an emergent problem such as obesity, decisions to act often must be made in the face of a relative absence of evidence, or evidence that is inconclusive, inconsistent, or incomplete. Evidence gathered from a particular intervention implemented in a closely controlled manner within a specific population with its own unique characteristics is often difficult to apply to a similar intervention with another population. The typical way of presenting results of obesity prevention efforts in journals often adds to the problem of incomplete evidence because useful aspects of the research related to its generalizability are not reported. If obesity prevention actions must be taken when evidence is limited, this incomplete evidence can be blended with theory, expert opinion, experience, and local wisdom to make the best decision possible. The actions taken then should undergo critical evaluation, the results of which should be used to build credible evidence for use in decision making about future efforts. Important alternatives to waiting for the funding, implementation, and publication of formal research on obesity prevention are natural experiments as sources of practice-based evidence, “evaluability assessment” of emerging innovations (defined as assessing whether a program is ready for full-scale evaluation), and continuous quality assessment of ongoing programs. The L.E.A.D. framework process leads to knowledge integration, or the incorporation of new knowledge gained through the process of applying the framework into the context of the organization or system where decisions are made.

The evidence base to support the identification of effective obesity prevention interventions is limited in many areas. Opportunities to generate evidence may occur

at any phase of the evidence review or decision-making process. The L.E.A.D. framework guides the generation of evidence related to “What,” “Why,” and “How” questions and supports the use of multiple forms of evidence and research designs from a variety of disciplines. In obesity prevention–related research, the generation of evi dence from evaluation of ongoing and emerging initiatives is a particular priority.

Researchers, decision makers, and intermediaries working on obesity prevention and other complex multifactorial public health problems are the primary audiences for communicating and disseminating the L.E.A.D. framework. With sufficient information, they can apply the framework as a guide for generating needed evidence and supporting decision making. It is important to understand the settings, communication channels, and activities of these key audiences to engage and educate them effectively on the purpose and adoption of the framework. To support the development of a communication and dissemination plan, it is critical to create partnerships, make use of existing activities and networks, and tailor the messages and approaches to each target audience.

As the target audiences begin to use the framework, assessing its use in selected settings will be essential so it can be improved and refined. Evaluation of the impact of the L.E.A.D. framework is also important for determining its relevance to current evidence-generation and decision-making processes. To this end, key outcome measures—utilization, adoption, acceptance, maintenance, and impact—should be defined and data collected on these measures. It will be important to develop or adopt data collection tools and utilize methods and existing initiatives that will best serve this purpose, as well as to systematically integrate the feedback thus obtained to sustain and improve the framework’s applicability and utilization.

RECOMMENDATIONS

The United States has made progress toward translating science into practice in the brief time since the obesity epidemic was officially recognized. But the pace of this translation has been slow relative to the scope and urgency of the problem and the associated harms and costs. As discussed above, moreover, the evidence emerging from applied research on obesity prevention can be inconclusive, incomplete, and inconsistent. A systematic process is needed to improve the use of available evidence and increase and enhance the evidence base to inform decisions on obesity prevention and other complex public health problems. Commitment to such a process is needed from both decision makers and those involved in generating evidence, including public and private policy makers and their advisors, scientific and policy think tanks, advocacy groups and stakeholders, program planners, practitioners in public health and other sectors, program evaluators, public health researchers and research scientists, journal editors, and funders. With this in mind, the committee makes the following recom-

mendations for assisting decision makers and researchers in using the current evidence base for obesity prevention and for taking a systems-oriented, transdisciplinary approach to generate more, and more useful, evidence.

Utilize the L.E.A.D. Framework

Recommendation 1: Decision makers and those involved in generating evidence, including researchers, research funders, and publishers of research, should apply the L.E.A.D. framework as a guide in their utilization and generation of evidence to support decision making for complex, multifactorial public health challenges, including obesity prevention.

Key assumptions that should guide the use of the framework include the following:

A systems perspective can help in framing and explaining complex issues.

The types of evidence that should be gathered to inform decision making are based on the nature of the questions being asked, including Why? (“Why should we do something about this problem in our situation?”), What? (“What specifically should we do about this problem?”), and How? (“How do we implement this information for our situation?”). A focus on subsets of these questions as a starting point in gathering evidence explicitly expands the evidence base that is typically identified and gathered.

The quality of the evidence should be judged according to established criteria for that type of evidence.

Both the level of certainty of the causal relationship between an intervention and the observed outcomes and the intervention’s generalizability to other individuals, settings, contexts, and time frames should be given explicit attention.

The analysis of the evidence to be used in making a decision should be summarized and communicated in a systematic, transparent, and transdisciplinary manner that uses uniform language and structure. The report on this analysis should include a summary of the question(s) asked by the decision maker; the strategy for gathering and selecting the evidence; an evidence table showing the sources, types, and quality of the evidence and the outcomes reported; and a concise summary of the synthesis of selected evidence on why an action should be taken, what that action should be, and how it should be taken.

If action must be taken when evidence is limited, this incomplete evidence can be blended carefully and transparently with theory, expert opinion, and collaboration based on professional experience and local wisdom to support making the best decision.

Sustained commitments will be needed from both the public and private sectors to achieve successful utilization of the various elements of the L.E.A.D. framework in future evidence-informed decision making and evidence generation. This respon-

sibility lies with the academic and research community, as well as with government and private funders and the leadership of journals that publish research in this area. Necessary supports will include increasing understanding of systems thinking and incorporating it into research-related activities, creating and maintaining resources to support the utilization of evidence, establishing standards of quality for different types of evidence, and supporting the generation of evidence, each of which is described in more detail below. Finally, it will be necessary to communicate, disseminate, evaluate, and refine the L.E.A.D. framework.

Incorporate Systems Thinking

Recommendation 2: Researchers, government and private funders, educators, and journal editors should incorporate systems thinking into their research-related activities.

To implement this recommendation:

Researchers should use systems thinking to guide the development of environmental and policy interventions and study designs.

Government and private funders should encourage the use of systems thinking in their requests for proposals and include systems considerations in proposal evaluations.

Universities, government agencies such as the U.S. Centers for Disease Control and Prevention, and public health organizations responsible for educating public health practitioners and related researchers should establish training capacity for the science and understanding of systems thinking and the use of systems mapping and other quantitative or qualitative systems analysis tools.

Journal editors should encourage the use of systems thinking for addressing complex problems by developing panels of peer reviewers with expertise in this area and charging them with making recommendations for how authors could use systems thinking more effectively in their manuscripts.

Build a Resource Base

Recommendation 3: Government, foundations, professional organizations, and research institutions should build a system of resources (people, compendiums of knowledge, registries of implementation experience) to support evidence-based public policy decision making and research for complex health challenges, including obesity prevention.

The Secretary of Health and Human Services, in collaboration with other public- and private-sector partners, should establish a sustainable registry of reports on evidence for environmental and policy actions for obesity prevention.

Integral to this registry should be the expanded view of evidence for decision making on obesity prevention proposed in this report and the sharing of experiences and innovative programs as the evidence evolves. A service provided by this registry should be periodic synthesis reviews based on mixed qualitative and quantitative methods.

The Secretary of Health and Human Services, in collaboration with other public- and private-sector partners, should develop and fund a resource for compiling and linking existing databases that may contain useful evidence for obesity prevention and related public health initiatives. This resource should include links to data and research from disciplines and sectors outside of obesity prevention and public health and to data from nonacademic sources that are of interest to decision makers.

Establish Standards for Evidence Quality

Recommendation 4: Government, foundations, professional organizations, and research institutions should catalyze and support the establishment of guidance on standards for evaluating the quality of evidence for which such standards are lacking.

Government and private funders should give priority to funding for the development of guidance on standards for evaluating the quality of the full range of evidence types discussed in this report that are useful in making obesity prevention decisions, especially those for which the scientific literature is limited.

Professional organizations and research institutions should encourage and bring attention to efforts by faculty, researchers, and students to establish guidance in this area.

Support the Generation of Evidence

Recommendation 5: Obesity prevention research funders, researchers, and publishers should consider, wherever appropriate, the inclusion in research studies of a focus on the generalizability of the find ings and related implementation issues at every stage, from conception through publication.

Those funding research in obesity prevention should give priority to support for studies that include an assessment of the limitations, potential utility, and applicability of the research beyond the particular population, setting, and circumstances in which the studies are conducted, including by initiating requests for applications and similar calls for proposals aimed at such studies. Additional ways in which this recommendation could be implemented include adding crite-

ria related to generalizability to proposal review procedures and training reviewers to evaluate generalizability.

Obesity prevention researchers and program evaluators should give special consideration to study designs that maximize evidence on generalizability.

Journal editors should provide guidelines and space for authors to give richer descriptions of interventions and the conditions under which they are tested to clarify their generalizability.

Recommendation 6: Research funders should increase opportunities for those carrying out obesity pre vention initiatives to measure and share their outcomes so others can learn from their experience.

Organizations funding or sponsoring obesity prevention initiatives—including national, regional, statewide, or local programs; policy changes; and environmental initiatives—should provide resources for obtaining practice-based evidence from innovative and ongoing programs and policies in a more routine, timely, and systematic manner to capture their processes, implementation, and outcomes. These funders should also encourage and support assessments of the potential for evaluating the most innovative programs in their jurisdictions and sponsor scientific evaluations where the opportunities to advance generalizable evidence are greatest.

Research funders, researchers, and journal editors should assign higher priority to studies that test obesity prevention interventions in real-world settings in which major contextual variables are identified and their influence is evaluated.

Recommendation 7: Research funders should encourage collaboration among researchers in a variety of disciplines so as to utilize a full range of research designs that may be feasible and appropriate for evaluating obesity prevention and related public health initiatives.

As part of their requests for proposals on obesity prevention research, funders should give priority to and reward transdisciplinary collaborations that include the creative use of research designs that have not been extensively used in prevention research but hold promise for expanding the evidence base on potential environmental and policy solutions.

Communicate, Disseminate, Evaluate, and Refine the L.E.A.D. Framework

Recommendation 8: A public–private consortium should bring together researchers, research funders, publishers of research, decision makers, and other stakeholders to discuss the practical uses of the

L.E.A.D. framework, and develop plans and a timeline for focused experimentation with the frame work and for its evaluation and potential refinement.

Interested funders should bring together a consortium of representatives of key stakeholders (including decision makers, government funders, private funders, academic institutions, professional organizations, researchers, and journal editors) who are committed to optimizing the use of the current obesity prevention evidence base and developing a broader and deeper base of evidence.

This consortium should develop an action-oriented plan for funding and implementing broad communication, focused experimentation, evaluation, and refinement of the L.E.A.D. framework. This plan should be based on the major purposes of the framework: to significantly improve the evidence base for obesity prevention decision making on policy and environmental solutions, and to assist decision makers in using the evidence base.

To battle the obesity epidemic in America, health care professionals and policymakers need relevant, useful data on the effectiveness of obesity prevention policies and programs. Bridging the Evidence Gap in Obesity Prevention identifies a new approach to decision making and research on obesity prevention to use a systems perspective to gain a broader understanding of the context of obesity and the many factors that influence it.

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Research Proposal Childhood Obesity

Valery Delgado

Prof. Elisabeth von Uhl

ENGL 21002 M

Research Proposal

December 11, 2018

Childhood Obesity: A Hidden Issue Within Public Schools

THE PROBLEM:

Obesity has become a nationwide health epidemic that continues to expand from children to adults. Indeed, being overweight poses a higher risk for many other health problems to arise including but not limited to diabetes, high blood pressure, high cholesterol, and heart disease. Moreover, studies such as the one proposed by Roger et al. illustrates the increase frequency of childhood obesity observed in low-income neighborhoods due to the of lack resources in regards  health risk associated with obesity. With this in mind, this growing issue is a prevalent concern that continues to not be fully address in many public schools in the Bronx county. Being a former student i n the Mohegan Public School 67 and having the opportunity to observe the continuous disregard of health science information to young students is problematic.

Furthermore, some of these students continue to be exposed to easily accessible sugary and unhealthy food within and outside the perimeters of the school. Additionally, these children are not encourage to participate in different physical activity in school. On the other hand, many of these students already suffer from excess amount of weight causing them to lack motivation to perform any form of physical activities. In addition, it was observe that many of these students avoid interacting or playing with other children in the playground, but prefer consuming unhealthy snacks. Therefore, all public schools should provide new alternatives to teach children and parents the importance of a healthy meals, negative effects of unhealthy snacks and the risk associated with obesity.

BACKGROUND:

Certainly, childhood obesity continues in being a growing problem in the United States among children and adolescents leading to greater health risk among the youth. According to the CDC (2018), “obesity is prevalent among children and adolescents between the ages of 2 to 19 years old.” In addition, the CDC(2018) reported that “obesity prevalence was 13.9% for 2 to 5 year olds, 18.4% for 6 to 11 years old and 20.6% for 12 to 19 years old.” The data illustrates a positive correlation between the older ages and higher obesity which indicates that as these children become older they also become less aware of the possible issues associated with obesity. Additionally, Cynthia et al (2010) proposed a study that emphasizes the long term effects of childhood obesity lingering into adulthood. As a result, obesity can lead to higher probability of developing cardiovascular complications including high blood pressure, high cholesterol and diabetes. Interesting, the study also reveal that obesity was prevalent among low-income population compared to population in higher socioeconomic status. Therefore, one can expect that the lack of resources like money and access to nutritional food to be contributing factors towards higher obesity levels in children.

Moreover, another study reveals that “there seems to be a relationship between certain ethnic groups and their low socioeconomic status” (Rogers et al, 2015). The study states that childhood obesity is a common disease in low-income communities among Hispanic and non-Hispanic Black populations. Additionally, the CDC data demonstrates that there is a higher prevalence of childhood obesity among Hispanic and non-Hispanic Black  population with a prevalence rate of up 25.8% and 22% respectively, while the childhood obesity rate of non-Hispanic white is much lower at 14.1% (2018). Such discrepancies in obesity rates possibly suggest that children and parents in minority communities lack health related information. Another consideration can be attributed to low income neighborhoods which are predominantly African American and Hispanic so the obesity rate could be expected to be much higher in these communities. Rogers et al study also states that “African American and Hispanics children within the low socioeconomic status are most likely to be in the overweight or obese category“(2015).

LITERATURE REVIEW:

These studies demonstrates that childhood obesity is not just present in low-income populations but emphasises additional factors that increases the likelihood of these children developing obesity as a long term health problem. Public schools in the city usually allow students to purchase inexpensive unhealthy meals from vending machines or fast food stands that are easily accessible throughout the neighborhood. As a result, these students have a higher consumption rate of sugary snacks which limits their physical motivation to participate in any physical activity. For instance, “33% of children and 41% of adolescents on average had consumed meals from a fast food restaurant”(Poti et al, 2014). The reason why majority of  children pick unhealthy meals is primarily due to the inexpensive prices of unhealthy snacks like chips, cookies and candy as “most likely, the availability of unhealthy sustenances are predominant in low income neighborhoods” (Rogers et al, 2015). Moreover, the price convenience outweighs the nutritious options not only in the eyes of the children but also the parents as “fast food intake is correlated with dietary preferences, access to fast food places and income constraints, influence how individuals eat throughout the day (Poti et al, 2014). However, parents are not noticing the poorer eating habits being taught to their children.

Interestingly, the average amount of calories intake continues to increase among children and adolescents. The environmental factors of nearby fast food places and limited budget is a influencing factor for fast food consumption. In addition, “fast food are higher in solid fat then in food consumed from retail stores or schools and few items on children menu align with national nutrition standards or dietary guidelines” (Poti et al, 2014). Children are not meeting the daily requirement of nutrition because fast foods have a higher concentration of fat which contributes to weight gain. Therefore, public schools can be used as the intermediate for children and parents to acknowledge the risk associated with obesity and unhealthy eating.  

Additionally, “obesity severely affects children in low income households with 18.9% of children and adolescents between 2 to 19 years old being classified as obese” (CDC,2018). Consequently, “obesity prevalence increased by 23 to 33% for children in low income families” (Rogers et al, 2015). In addition, “23.7% of African Americans between the ages of 12 to 19 were considered obese, while whites within the same age group had 16.1% of obesity prevalence”(Rogers et al, 2015). African Americans live in low income area compared to Caucasians that are part of the high socioeconomic status. Indeed, these children that grow up in low-income population have a higher possibility of developing obesity due to the limitations not only within their communities but also the public schools they attend..

OBJECTIVES:

The long term goal of this research is to develop an educational program within public schools that would teach children and parents of the benefits of healthy eating, promoting physical activity and risks associated with the constant consumption of unhealthy eating habits. The information gathered from multiple studies can be used to develop an outline with the contributing factors that can potentially caused health related problems such as obesity among children and adolescents.

For the study under Cynthia L.Ogden et al (2010) examined the relationship of obesity and socioeconomic status among children and adolescents. Indeed, the study illustrated the correlation between childhood obesity and income status of the household head. One of the results found that children and adolescents living with the head of a household with a college degree are less obese than those without an education. As stated before, low income children and adolescents had a higher obesity rate compared to those of a higher economic status. Therefore, both of these findings demonstrated that the prevalence of obesity decrease as income increases which can suggest that limitation of knowledge is possible cause of unhealthy eating habits.

In addition, Rogers et al (2015) study further examined the relationship of obesity between ethnic groups and socioeconomic status. The results indicated a higher rate of obesity present in children of  African Americans and Hispanics in low income status compared to their Caucasian counterpart. Alternatively, families of low income status were less likely to notice their children being overweight. Therefore, lower household income is associated with higher prevalence of obesity among children.

Furthermore, the Jennifer M. Poti et al (2014) study demonstrated the association of fast food intake with poor diet is abundant pattern among obese children. The results concluded that half of  U.S children consumed fast food on a daily basis. From previous observation during a field site view of the Mohegan Public school, such findings are relevant with the eating habits present among the students. As a result, fast food consumption was correlated with obesity or overweight among children.

The Center for Disease Control (2018) provided a national representative sample about the prevalence of childhood obesity in the United States. The results provided the percentage of obesity for each of the three age groups such as 2 to 5 year olds, 6 to 11 years old and 12 to 19 years old. In addition, children within minority communities like Hispanic and African Americans had a higher obesity prevalence compared to their Asian and White counterpart. Furthermore, obesity prevalence was higher in low income group and families that lacked a education. Overall, ethnicity and socioeconomic status are the contributing factors of childhood obesity.

In order to develop a guideline of prevalent information for public schools to use as in outline for parents and students, a study will be developed to test whether the information provided can expand awareness of health risk associated with unhealthy lifestyle activities. The focus group will include a sample size consisted of children between the ages of elementary and middle school and if possible the parents could participate. Participants will be randomly selected from the Mohegan Public School 67. Next, A educational program will be provided to inform the participants about healthy eating, the benefits of physical activities and risk of unhealthy eating.

Afterward, each participant will completed a 20 question survey. The questionnaire will contain a series of questions focusing on various topics expanding from preference in physical activities, eating habits, knowledge of health risk issues. The answers will be recorded as an scale that will range from strongly agree to strongly disagree. Furthermore, through data analysis the most important prevalent information will be gathered depending on the common answers among the subjects. At this point, an educational outline could be provided to the school for further testing with a larger sample size. The final outline will need to be tested on multiple trials to condense the information into a format that is understandable for both children and parents.

CONCLUSION:

Overall, many students within public schools  are constantly exposed to unhealthy eating habits that also prevents from participation in physical activities. These children and adolescents can or will be consider overweight and obese which would most likely continue to negatively affect them during adulthood. Indeed, obesity can lead to further health complications. There are certain factors that contribute to childhood obesity such as ethnicity, income and education. However, there is a possible solutions to reducing obesity among the youth. As a recommendation, a continuous program can be develop to educate these young minds about healthy eating and positive thinking as this should be a standard application within public schools in order to prevent and hopefully lower the cases pertaining health related issues from childhood obesity.

Works Cited

“Childhood Obesity” CDC,  August 13, 2018 https://www.cdc.gov/obesity/data/childhood.html

Cynthia L.Ogden, Ph.D.; Molly M.Lamb, Ph.D.; Margaret D. Carroll, M.S.P.H.; and Katherine

• Flegal, Ph.D ( December 2010) Obesity and Socioeconomic Status in Children and Adolescents: United States. 2005-2008. U.S Department of Health and Human Services. No.51

Jennifer M. Poti, Kiyah J Duffey, and Barry M. Popkin (2014). The association of fast food consumption with poor dietary outcomes and obesity among children: is is the fast food or the remainder of the diet. The American Journal of Clinical Nutrition   99(1):162-71.

Robert Rogers, BA, Taylor F. Eagle, BS, Anne Sheetz, MPH, Alan Woodland, MD, Robert Leibowitz, PhD, Minkyoung Song, PhD, RN, FNP-BC, Rachel Sylvester, BS, Nicole Corriveau, BS, Eva Kline- Rogers, MS, RN, Qingmei Jiang, MA, MS, Elizabeth A. Jackson, MD, MPH, and Kim Eagle, MD ( Dec 1. 2015)  The Relationship between Childhood Obesity, Low Socioeconomic Status, and Race/Ethnicity: Lessons from Massachusetts. 11(6): 691–695.

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