The overall data seen in our outpatient clinic analysis did indicate a high association of obesity with the comorbid conditions of diabetes mellitus and hypertension. Indeed, this is a well-known fact, being that the high preponderance of insulin resistance and elevated insulin levels in individuals with excessive adiposity leads to the individual’s inability to handle excessive glycemic loads. It is also known that increased levels of insulin result in fluid and sodium retention thus increasing the risk for hypertension in patients with excessive adiposity and insulin resistance [14]. These findings were not surprising and were found statistically significant. These findings also present an opportunity for action by clinicians. They must see and treat obesity as a disease entity that directly leads to other health risks with serious negative long-term impacts. Although the time for patient counseling in the clinics is limited in today’s typical practice setting, consideration for a multidisciplinary, team-based approach may yield better results. A broad spectrum of counseling for lifestyle modifications concerning nutrition, exercise, and mental wellness should be made a routine part of care for obese patients. The team may include physicians/providers, health coaches, nutritionists, psychologists, case management health workers, and/or physical therapists to ensure better patient outcomes [15].

The two other measures that we explored in association with obesity were COPD and depression, but they were not found to be statistically significant for our population. However, previous studies noted that depression is higher in individuals with obesity [16] although the exact mechanism is unknown and many factors including hormonal, inflammatory, and sleep disruptive causes, among others have been implicated. Cultural pressures locally may influence accurate patient reporting of depression symptoms since many of these may be considered personal weakness amongst certain ethnic groups and gender [17,18]. However, obese patients tend to be more depressed as they are physically limited in functional capability in many cases, as well as personal image issues from peer influences. Sometimes it is challenging to determine which came first, obesity which may make the individual emotionally sad/depressed or depression which may lead to emotional eating and eventually to obesity.

Demographic analysis, when accounting for payor/insurance status, revealed the higher likelihood of obesity among those individuals with private insurance although less than the combined groups of those patients who had public assistance insurance and those with no health insurance. This did support our suspicion locally of the idea that obesity is currently viewed as a disease of poverty [19]. Also, the rural Northeast Texas region is one of the more impoverished locations in the state of Texas [20]. Many food deserts exist here, leading to higher consumption of fast foods/processed foods and less healthy eating due to limited access to healthier fresh food options. This situation contributes to increasing obesity rates with comorbid conditions as noted earlier. In this analysis, females were also found to be more likely to be obese. Individuals identified as black race/ethnicity were also more likely to have excessive weight, and those individuals in the 40-65 age demographic were more likely than not to be obese. These facts confirm the problem of disparities which are rooted in the major factors of social determinants of health. Factors such as lack of insurance and limited access to care may stem from unemployment which may be related to limited or no education. Undeniably, many of these challenges are outside the scope of the healthcare provider whose role is to see patients when they are scheduled. However, healthcare providers may join in the advocacy for healthcare access for the disparate populations. Also focused nutrition and multidisciplinary education should target this group in public health promotion efforts.

As previously mentioned, primary care providers are in a vantage position to address the epidemic of obesity with associated comorbid conditions. Indeed, primary care providers are the largest stakeholders in providing care for individuals with obesity and related comorbid conditions, such as diabetes mellitus, hypertension, sleep apnea, and many others. Unfortunately, primary care providers are often tasked with increasing numbers of patients to see each day which limits how much time they spend with each patient, as well as the quality of time with each patient. Decreasing revenues and the looming advent of pay for performance without proper infrastructure and built-in support systems may strain the clinician’s ability to care for these patients. When this is combined with increasing costs of diagnostics and medications, it is very difficult to assure optimal care and positive health outcomes for those patients requiring the most effort. This not only frustrates patients but also providers who are unable to provide the necessary time and care to improve the patient’s health in a meaningful way.

Findings from this study confirm the need to consider changes in the paradigm with respect to caring for patients with obesity, metabolic syndrome, and all associated conditions and comorbidities. Rather than attacking symptoms (e.g. insulin resistance, diabetes mellitus, hypertension, sleep apnea), providers are more likely to make a larger impact if given the tools, time, and resources to attack the root cause of all these conditions. Since obesity and excessive abdominal and visceral adiposity have consistently shown to increase the risk of comorbid conditions, tackling the issues that lead the patient to the path of obesity may offer a much more positive impact on patient health and curb the current obesity crisis. As research and our knowledge about obesity continue to improve, it is has become evident that this is a much more complex disease process than the paradigm of ‘calories in, calories out’. There is need to a focus on the role of multiple factors that must be considered, like brain pathways and chemistry, endocrinopathies, genetics, diet, exercise/activity, mental health, and even gut flora. All these may have a role in a patient’s case and maybe the cause for excess weight and thus, in turn, multiple comorbidities. Allowing a provider more time to address the multiple causes factoring into a patient’s excessive weight and by enlisting a multidisciplinary approach (behavioral health counseling, physical therapy and/or personal trainers, sleep medicine, registered dieticians, bariatric surgery, geneticists) to treat the patient should be strongly considered for the future if the battle has to be won against the complex disease of obesity which is constantly on the rise instead of in decline [21]. Beyond further research, the solution may come from serious collaborations between healthcare systems/providers, government, the food industry, and insurance carriers, for better results.