“Severe” or “Class III” obesity is defined as having a BMI greater than or equal to 40 kg/m2. These individuals are approximately 100 – 200 pounds or more heavier than their normal weight counterparts. This excess weight results in significantly higher chronic disease risks (heart disease, diabetes, stroke, cancer, etc.).128 Further, individuals who are severely obese are more likely to encounter complications with medical interventions, which often necessitates a longer hospital stay.137 Because of these factors, and others, severely obese patients incur
healthcare costs significantly higher compared with their overweight (BMI 25 – 29.9 kg/m2) and obese (BMI 30 – 39.9 kg/m2) counterparts.1,137,138 In their 2010 study, Finkelstein et al. report that the medical treatment expenses of individuals who are severely obese are approximately 100% higher than their normal weight counterparts. The number of individuals who are severely obese in the US is growing at twice the rate of the obese population (those with a BMI between 30 kg/m2 and 39.9 kg/m2, Classes I and II).1 Finkelstein et al predict that severe obesity
prevalence in the year 2030 will be approximately 11% (a 130% increase from 2010).218
Commensurate with patterns observed across all categories of BMI, the risk of becoming severely obese varies by both race and gender. Data from the National Health and Nutrition Examination Survey indicate that in 2010 African American women were more than twice as likely to be severely obese than their Caucasian counterparts (18% vs. 8%).140 Research on effective treatments for severe obesity should prioritize developing treatments for groups who are at highest risk–in this case, African American women—for two reasons. First, helping those most at risk can have the biggest impact (positive) on the adverse health and economic outcomes of severe obesity. Second, risk disparities—especially those that are as large as the ones here— are the fundamental cause of health disparities. Addressing health disparities has been a priority
for the past two decades for the Healthy People initiative. In Healthy People 2020 the goal is “to achieve health equity, eliminate disparities, and improve the health of all groups”.139
Multiple studies and reviews indicate that bariatric surgery is clearly an effective treatment for reducing body weight in individuals who are severely obese.141 And, for certain populations, weight loss surgery is an appropriate option. However, the major focus on this form of treatment.142,249 for severely obese populations—to the relative neglect of all others—is
concerning for several reasons. First, concerns remain about the ability of this type of treatment to meet the growing population demand; only 1% of all severely obese adults in the US undergo bariatric surgery each year.142 There are likely many reasons for this low rate including
individual patient decisions, inability to meet presurgical requirements, inadequate or non- existant insurance coverage and/or being denied by an insurance provider. Disparities of uptake of bariatric surgery among minority groups are also clearly evident. For example, African Americans make up 21% of all individuals who are eligible for bariatric surgery yet only 9% of those undergoing bariatric surgery are African American; whereas 67% of those eligible for bariatric surgery are Caucasian and 67% of those receiving treatment are Caucasian.148 Reasons for this disparity are not entirely clear, but preliminary data are suggestive of factors that are not easily subject to modification including: inadequate insurance coverage,149 economic
concerns.149 and cultural preferences.57
The focus on bariatric surgery as a treatment for severe obesity has resulted in a paucity of information on how to design BWL interventions for individuals who are severely obese. Developing effective BWL interventions for individuals who are severely obese is important for two reasons. First, as discussed previously, bariatric surgery alone is not sufficient to meet the diverse needs of the growing severely obese population. As reported by Blackburn et al. (2010)
“Although weightloss surgery is the most effective treatment, it offers little in the way of largescale containment due to its costly and invasive nature. BWL interventions that induce modest weight loss and improve fitness can significantly lower disease risk…[and, therefore]…. should be a high priority in nutrition medicine”.250 Second, BWL interventions teach important skills that will be important for weight maintenance after bariatric surgery.251 Only a small handful of quality BWL intervention studies with individuals who are severely obese have been published.142,156,249 However, findings from these studies with racially heterogeneous samples indicate that BWL interventions are desired and feasible and most importantly, they can produce clinically significant weight losses. Additional details regarding the sample demographics and weight loss outcomes for these three studies can be found in Table 5.
The efficacy of public health interventions can be greatly improved through targeting, or “developing…a single intervention approach for a defined population sub-group [taking] into account characteristics [that are] shared by the sub-group’s members”.172,252 Two of the most relevant characteristics of our target population—African American women who are severely obese—are culture and extremely high body weight. A handful of published studies contain information that could be used to tailor interventions for heterogeneous groups of individuals who are severely obese and also for overweight and moderately obese African American women. However, no studies could be found focusing specifically on interventions for African American women who are severely obese. In this paper we describe the program design rationale for a targeted BWL intervention for African American women who are severely obese based on a review of the literature and formative research conducted by our team. We also report the findings of a pilot study conducted to test feasibility.