1

Obesity in Puerto Rico

Xavier García-Collazo

University of Maryland

FMSC110S: Families and Global Health

Dr. Elisabeth Maring

November 19, 2020

I pledge on my honor that I have not given or received any unauthorized assistance on this

assignment/examination.

Xavier García-Collazo
 2

Introduction

Obesity is a serious global health issue that impacts families across the world. It can lead

to a lower quality of life, impacting the psychological, physical and social well-being of

individuals. The World Health Organization (WHO) defines being overweight and obese “as [an]

abnormal or excessive fat accumulation that presents a risk to health.” The body mass index

(BMI), based on weight-for-height, is used to classify overweight or obese individuals. Thus, a

person with a BMI over 25 is regarded as overweight and over 30 is obese (WHO).

Obesity leads to many health complications such as cancer, cardiovascular disease, diabetes, and

body structural issues (e.g., musculoskeletal). Worldwide, obesity has grown with the power of

an epidemic with 1.9 billion adults affected as of 2016 and an estimated 4 million deaths per

year. According to the Centers for Disease Control and Prevention (CDC), in the United States

(US) the prevalence of obesity in adults was 42.4% between 2017-2018, and 18.5% in youth 2-

19 years of age in the years 2015–2016. In Puerto Rico, the overall obesity prevalence is between

30-35%, ranking high among the regions of obesity in the US (CDC). Thus, addressing the

health issues of obesity in Puerto Rico is a top priority of the island’s government (Sánchez-

Hernández, 2012). The most important aspect to keep in mind about obesity is that it is

preventable.

Background

This health issue does not discriminate based on age, wealth or race, but it is mostly a

direct consequence of an individual’s actions and possibly genetics. In the US, certain trends in

obesity disparities that have been described. One pattern observed was that there is a prevalence

of obesity in certain racial groups and ethnicities. For example, the highest prevalence of obesity
 3

was in non-Hispanic blacks (49.6%), followed by Hispanics (44.8%), and non-Hispanic whites

(42.2%) (CDC). In particular, the Hispanic community in 15 states in the US had a 35%

prevalence of obesity and overweightness. Another trend found was related to the educational

level and how it corresponds with the risk of obesity prevalence. It was observed that persons

with the highest degree of education (college) had the lowest levels of obesity (CDC). Within the

US, the CDC measured that the highest prevalence of this issue was located in Mississippi (40.8)

and West Virginia as the second most (39.7). According to all variables such as race, ethnicity

and risky behavior linked to the level of education, these two states were found to consistently be

in the top two. Disparities based on gender have also been documented. For example, according

to Pérez et al. (2013), the prevalence of obesity in Puerto Rico was higher in lower-income and

non-smoking women. Despite the development of many policies and programs, obesity

continues to increase in the US. Most of the needed interventions will inevitably be the

responsibility of the individuals and their lifestyle choices.

Hispanics are a large ethnic minority population in the US and they experience a variety

of health disparities. This paper will focus on Puerto Rico and how obesity affects the residents

of the island. Studies have noted that many of the residents in Puerto Rico are more susceptible

to obesity, especially children and young adults. For example, a study conducted on the island

evaluated 1,582 twelve-year-olds (Elías-Boneta et al., 2015). The goal of the study was to

determine the BMI prevalence within this group. The sample was selected from 133 schools

(both private and public) and 10 boys and 10 girls were selected from each school. The study

found that from the selected population, 18.8% of children were overweight and 24.3% were

obese. These numbers were found to be higher than the obesity prevalence in the US. The study

also found that boys were more susceptible to obesity than girls (28.2% versus 20.2%,
 4

respectively). Lastly, it was found that obesity mainly affected low- and middle-class families

that inhabited the island. A key message from the study was that Puerto Ricans were in dire need

of public health policy implementations and educational opportunities to inform and, hopefully,

improve the overall health of the public. A roadblock preventing the development of these

services is the poor condition of the socio-economic system on the island (Elías-Boneta et al.,

2015). Ultimately, addressing issues with obesity and developing interventions in this age group

are essential since eating habits and healthy behaviors developed in a young age are taken to

adulthood.

Significance

Obesity and overweightness do not primarily affect one region, but it is a critical health

issue found across the globe. The United Nations (UN) introduced 17 Sustainable Development

Goals (SDGs) to provide a framework for ending poverty, protecting the planet, and ensuring all

people experience safety and prosperity on a global scale by 2030. With this system in place, the

UN hopes that improvement in any of the 17 SDGs will create a chain reaction of progress in

other categories. Multiple countries have integrated the SDGs and the “Leave no One Behind”

policy in order to fast track the improvement of those regions in extremely precarious situations.

Obesity itself falls under the SGD #1: No Poverty, SGD #2: Zero Hunger, and SGD #3: Good

Health and Well-Being. For No Poverty, the UN found that 736 million people worldwide live in

extreme poverty and 50% of those people are under 18 years of age. The big issue behind

persisting poverty is that it impedes any educational or preventative measures from being

established in many countries in order to help and inform the public of the dangers behind

obesity. With the presence of poverty, obesity becomes a credible threat to another goal, Good

Health and Well-Being. The UN claimed that 400 million people worldwide do not have access
 5

to basic healthcare and 1.6 billion people live in fragile and unsustainable environments. The

lack of healthcare immediately contributes to those who lack education on the dangers of

obesity. This insufficiency actively works against the efforts made to improve the health of the

residents across the globe. Lastly, within the Zero Hunger goal, it is acknowledged that those

with obesity or overweightness are affected “by another form of malnutrition” and are inevitably

“at higher risk of early-onset obesity-related health and psychological complications” (UN). The

presence of excess weight will often be carried into early adolescence and adulthood,which will

burden the individual for life. Obesity, ultimately, poses a big threat against the success of these

goals and thus should be addressed when considering steps needed to create a positive impact on

the world (UN).

As mentioned previously, obesity has serious health consequences on the individual, but

it also has a tremendous impact at the family level. On the individual, obesity is often associated

with and can cause health issues such as heart disease, stroke, diabetes, hypertension, high

cholesterol, cancer, and bone structure issues. Obesity also increases the risk of severe COVID-

19 illness (CDC). Furthermore, this health issue can lead to many mental illnesses such as

depression and anxiety, often linked with struggles with self-image and negative social pressures

such as bullying. All these issues caused by obesity can have a major impact on an individual's

socioeconomic status, both directly and indirectly. Money could be directly poured into a

constant need for treatment and diagnostic care from healthcare professionals; it can also be

indirectly lost through a loss of productivity coming from the individual. Since an obese person

is susceptible to many health risks, this could also impact their job productivity due to frequent

absences linked to sickness (CDC). All of these factors contribute to an overall low quality of

life for the individual, but they also have an impact on the family level. For example, the
 6

increased presence of chronic and costly health issues surfacing on an obese child could create a

stressful environment for family members. The increased need for money expenses in order to

treat the possible diseases could put a strain on the family’s economic success. The effect on

mental health can weaken or even break the bonds being formed between family members. As

for future generations, obesity itself, other chronic illnesses, and cancer can become deeply

embedded in our society creating a great deal of resistance against any improvements.

Within the social ecological model, obesity most greatly affects the individual, the

microsystem and the macrosystem levels. Provided that most issues surrounding obesity can

create problems for the people on all these levels, it is important to know that obesity as a whole

can be most effectively prevented precisely on these levels. Through self-care, spread awareness

and policy/organization, this health issue can be fought and, hopefully, managed and prevented.

Ohri-Vachaspati et al. (2014) used the social ecological model to analyze obesity in children.

The authors found that the parent’s demographics and perceptions of their neighborhood had a

strong contribution in predicting if a child was obese or overweight. A smaller but significant

contribution to these predictions was also found in the food and physical activity levels. These

outcomes can help inform the development of strategies to address obesity in children.

Current Efforts

Due to the many health consequences associated with obesity, it is inevitable that there

would be a variety of interventions in hopes of combating obesity and the issues that arise from

it. In Puerto Rico, a study was done in 2016 to evaluate the impact of an intervention consisting

of a weekly plan for the participants that provided peer support, dietary guidance, physical

activity and stress reduction in order to promote a healthier lifestyle (Halperin et al., 2019). The
 7

study included a sample group of 39 young adults, 18-19 years of age, randomly

selected from the Inter-American University, all considered

overweight or obese. This population was selected because

intervention studies conducted in young adults in Puerto Rico have

not been published and approximately half of the 18-24 years of age

have a BMI ≥25. The timeline of the study consisted of a baseline day,

a 10-week period and a 6-month follow-up period. The study found

that the stress from college is linked to obesity through high

consumption of unhealthy foods for long periods of time. Many of the

students interviewed stated that the sources of stress in their lives

stemmed from their educational, economical and social environments.

Many of these stressors were reported to create difficulty with

weight management and had a high correlation in their inability to

control food consumption and exercise. The researchers decided that

the best way to go about this study was to combat stress directly

through the encouragement of positive social opportunities, the use

of health management programs, increased physical activity like

walking, and increased mindfulness from yoga and other health

practices.

All the subjects had their BMIs measured on the study timepoints. The baseline BMI in

the experimental group was 32.7. By the end of the 10-week period, the BMIs of the

experimental group decreased by 0.8 points and by 6 months it decreased by 1.2. In contrast, in

the control group, which received standard care consisting of educational materials on diet and
 8

physical activity, the baseline BMI was 29.5 and it increased by 0.7 in 10 weeks and by 0.8 in 6

months. The study also found that mindfulness and self reflection were key in combating stress

and promoting an overall healthier lifestyle. The experiment observed an obvious trend

suggesting that healthy practices such as yoga and a good diet would create positive results for

the individual.

Since the investigation focused mainly on the individual and how the BMI responded to

healthy practices, it would be interesting to evaluate how their grades, mental health and social

interactions improved from the baseline date to the 6-month period. Furthermore, the experiment

could have acknowledged how individuals on the microsystem (family) level were impacted

through the improvement of the subjects' lives during the experimental period. One limitation of

the study is the relatively small sample size. This could lead to false assumptions when

considering the population as a whole. Lastly, an important aspect that could be extremely

informative is how many subjects continued a healthy lifestyle past the 6 months follow-up

period and how their mental and physical health have been impacted by the improved behaviors

versus those who did not continue or never started the intervention. The study did not address the

many complications related to obesity and how it could affect the subjects. The follow-up data

collected at baseline, 10-week, and 6-month periods should have included laboratory screenings

to search for possible risks of chronic illness. In this regard, the authors acknowledged that the

decrease in BMI may not have been significant enough to have an impact on these clinical

measures. However, the study was able to offer promising results of weight loss through a

specific plan targeting Latino young adults, implying the importance of conducting research in

all age groups and how these prevention programs and positive practices can influence all

individuals and families across the globe. This research could hopefully be applied to young
 9

adults across the island and, hopefully, it could be made a part of intervention programs in

colleges across the US. One concern the study mentioned was how the Puerto Rican government

would be able to implement this system of obesity and overweight prevention more widespread

across a diverse population. Given the economic and social disadvantages, it is possible that

there would be a great amount of resistance behind the policy implementations in the Puerto

Rican government. It is important to acknowledge that, fundamentally, this study attempted to

provide education and programs to improve the lives of those who were in danger of obesity and

showed promising results (Halperin et al., 2019). Any attempt to resolve this issue, even on the

individual level, can create improvements on a global scale.

Discussion

As demonstrated in the intervention program designed by Halperin et al. (2019), a guided

schedule provided to persons who are overweight or obese shows positive results both mentally

and physically. This study provides the promise that programs such as dietary guides, physical

activity and mental well being could be implemented in colleges/universities globally in order to

ensure a healthier lifestyle for all students. These types of interventions can serve as a model that

can be implemented across entire communities. However, there are many inequities that need to

be addressed in Puerto Rico in order to facilitate the success of this program. Puerto Rico has a

unique set of challenges by frequently being impacted by natural disasters such as hurricanes and

earthquakes, tropical diseases such as dengue and zika, a high crime rate in some areas, political

instability, and a depressed economy. All of these disadvantages create impediments for

improvements in the SDGs: No Poverty, Zero Hunger and Good Health and Well-Being. With so

many priorities that need to be addressed, it is inevitable that obesity could be neglected.

However, every small effort will help solve this serious epidemic. For example, the Baby Act
 10

Trial (Pomeroy et al, 2018) is trying to address obesity in infancy by providing an intervention

focused on physical activity, healthy sleep and a healthy diet. Ultimately, developing

interventions that encompass all members of a population is going to be crucial to tackle obesity.

Conclusion

Obesity is a serious disease that impacts individuals, families and communities across the

globe. Obesity is linked to other chronic diseases which can create an intricate web of health,

mental and economic challenges. The metaphorical web spun by this health issue can be cut

down through preventive measures and lifestyle interventions in order to create a positive

outcome that begins at the individual and irradiates to the family and community levels. This

paper does not address genetic determinants or metabolic disorders that could play a role in an

individual’s predisposition to obesity. Thus, it would be of great interest to evaluate obesity

from a biological perspective, in addition to the socio-economic factors that contribute to this

serious and complex health issue.

 11

References

Adult Obesity Prevalence Maps. (2020, September 21). Retrieved November 16, 2020, from

https://www.cdc.gov/obesity/data/prevalence-maps.html

Elías-Boneta, A. R., Toro, M. J., Garcia, O., Torres, R., & Palacios, C. (2015, March 5). High

Prevalence of Overweight and Obesity Among a Representative Sample of Puerto Rican

Children. Retrieved November 16, 2020, from

http://content.ebscohost.com/ContentServer.asp?

T=P&P=AN&K=102015271&S=R&D=asn&EbscoContent=dGJyMNLe80Sep7A4zOX0

OLCmsEiep7BSrqy4S7GWxWXS&ContentCustomer=dGJyMPPj34r34ux8uePfgeyx44

Dt6fIA

Halperin, D. T., Laux, J., LeFranc-García, C., Araujo, C., & Palacios, C. (2019, February).

Findings from a randomized trial of weight gain prevention among overweight puerto

rican young adults. Retrieved November 16, 2020, from https://www-sciencedirect-

com.proxy-um.researchport.umd.edu/science/article/pii/S149940461830681X

Obesity and overweight. (n.d.). Retrieved November 16, 2020, from

https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight

Obesity. (n.d.). Retrieved November 16, 2020, from https://www.who.int/health-topics/obesity

Ohri-Vachaspati, P., DeLia, D., DeWeese, R. S., Crespo, N. C., Todd, M., & Yedidia, M. J.

(2015, August). The relative contribution of layers of the Social Ecological Model to

childhood obesity. Retrieved November 16, 2020, from

https://pubmed.ncbi.nlm.nih.gov/25374257/
 12

Pérez, C. M., Sánchez, H., & Ortiz, A. P. (2013, December). Prevalence of overweight and

obesity and their cardiometabolic comorbidities in Hispanic adults living in Puerto Rico.

Retrieved November 16, 2020, from https://pubmed.ncbi.nlm.nih.gov/23846388/

Pomeroy, J., Campos, M., & Palacios, C. (2018, May 24). Success of MCRI childhood obesity

study in Puerto Rico impacted by Hurricane Maria. Retrieved November 16, 2020, from

https://www.marshfieldresearch.org/News/success-of-mcri-childhood-obesity-study-in-

puerto-rico-impacted-by-hurricane-maria

Sánchez Hernández, E. (2012, July). Puerto Rico healthy people 2020 strategic plan. Retrieved

November 15, 2020, from http://www.salud.gov.pr/Estadisticas-Registros-y-

Publicaciones/Publicaciones/Healthy%20People%202020.pdf

Sustainable development goals report 2019. (n.d.). Retrieved November 16, 2020, from

https://unstats.un.org/sdgs/report/2019/