A new ranking establishes Temple University as one of the world’s leading research institutions addressing a truly endemic public health crisis—the ongoing rise of obesity in the United States. Driven by research at the Center for Obesity Research and Education (CORE) in the College of Public Health, the university ranks third in the world in the number of papers published in one of the field’s premier journals, Surgery for Obesity and Related Diseases, the flagship journal of the American Society for Metabolic and Bariatric Surgery.
“Prior to 2015, we had almost no work going on in this area. It is an amazing amount of growth and remarkable accomplishment,” says David Sarwer, CORE director and associate dean of research at the College of Public Health. “It shows what a truly multidisciplinary College of Public Health can do. We very quickly have become recognized as one of the world's leading research groups in the field of obesity.”
More than 40 percent of Americans now have obesity, defined as a Body Mass Index of 30 or higher (weight in kilograms divided by height in meters squared). It’s estimated that an additional third of Americans are overweight (BMI over 25). That puts about 70 percent of the population at risk for weight-related health problems, which can include heart disease, hypertension, type 2 diabetes, sleep apnea, osteoarthritis and forms of cancer. As a public health emergency, obesity gets fewer headlines than pandemics, but it’s a persistent problem that has not shown signs of improving.
Temple’s wide-ranging obesity research comes from investigators in six departments across the College of Public Health, as well as the Lewis Katz School of Medicine. Much of the work is done through CORE, a universitywide group of dedicated and affiliated investigators. CORE’s research team explores the etiology, prevention and treatment of obesity, with an eye toward early intervention and factors that influence childhood eating habits, from school breakfast policies to sleep duration and parents’ nutrition understanding. Their work is wide-ranging: Jennifer Fisher, professor in the Department of Social and Behavioral Sciences and director of CORE’s Family Eating Laboratory, recently co-chaired a panel developing national healthy eating guidelines for children ages 2 to 8, and CORE researchers have led programs promoting physical fitness and healthy eating in partnership with Philadelphia public schools and analyzed the relationship between adverse childhood experiences and childhood obesity.
Use and impact of bariatric surgery
CORE has developed an international reputation for its work in the area of bariatric surgery. There’s rising consensus that bariatric surgery can be a life-saving procedure, because of its powerful effects on weight-related health problems. That has generally meant diabetes and heart disease, but recent research has linked weight reduction surgery to improved COVID-19 outcomes, and College of Public Health research also links weight reduction surgery to better outcomes from hypertension, one of the major causes of premature death worldwide.
“Most of the literature is about weight change or diabetes. In fact, it's sometimes referred to as metabolic surgery,” says Gabriel Tajeu, assistant professor of health services administration and policy. “But its impact on hypertension suggests a major health benefit from the procedure that has been underappreciated.” In a review of literature, Tajeu found a strong link between bariatric surgery and improved hypertension outcomes. His review of studies found that patients needed fewer antihypertensive medications after bariatric surgery. In almost a third of the studies his team examined, greater than or equal to 75% of participants experienced hypertension remission following surgery, he says, and about 40% of the articles reported a decrease in systolic blood pressure greater than or equal to 10 millimeters of mercury after surgery.
“That would result in a staggering reduction in downstream cardiovascular disease outcomes, like heart attack and stroke,” he says.
Other College of Public Health faculty have been studying factors that contribute to successful bariatric procedures. Successful outcomes require patients to follow through with lifestyle changes. Too many don’t, notes Sara Kovacs, assistant professor of instruction in the Department of Kinesiology and a CORE affiliate researcher, who studied physical activity in patients after they undergo bariatric procedures.
“We were interested to see if there were psychosocial variables associated with physical activity following the surgery. There really was no literature,” Kovacs says. Her research showed patients generally not engaging in enough physical activity, despite its potential benefits. The study identified factors such as social support that might help, and the next step will be seeing whether a targeted intervention has an impact.
Jingwei Wu, assistant professor in the Department of Epidemiology and Biostatistics and a CORE affiliate, has collaborated on a number of studies investigating behavioral and physiological factors that relate to excessive weight gain and treatment response. He has been co-investigator with Sarwer in a study investigating patient mental health, disordered eating and impulsivity as predictors of bariatric surgery outcomes.
Despite the potential health benefits of bariatric surgery, the procedure has been underutilized, Sarwer says. As of 2016, more than 32 million U.S. adults were classified as having class II or III obesity (BMI 35–39.9 kg/m2)—approximately 10% of Americans—making them potential candidates for bariatric surgery. Yet only about 1 in 100 patients who meet BMI criteria undergo these procedures.
In a 2021 study, Hamlet Gasoyan, a former Temple doctoral student in the Department of Health Services Administration and Policy, investigated the role that health insurance coverage plays in the utilization of bariatric surgery options. The research found that individuals with traditional Medicare plans with no supplemental insurance had lower odds of undergoing surgery than those with private secondary insurance. Another 2021 paper, led by Sarwer with Gasoyan, CORE senior project director Jacqueline Spitzer, Sarah Bauerle Bass, director of temple’s Risk Communication Laboratory, and Rohit Soans and Daniel J. Rubin from the Lewis Katz School of Medicine, cited lack of awareness about bariatric surgery among patients, anecdotal concerns about safety, and weight stigma and bias and suboptimal communication between patients and providers.
At a national workshop discussion held by the National Academies of Sciences, Engineering, and Medicine in October, “Systems and Obesity: Advances and Innovations for Equitable Health and Well-Being,” Sarwer said the underuse of bariatric surgery reflects issues in health insurance coverage and benefits design, weight bias and stigma, and gaps in patient–provider communication.
Sarwer emphasized the importance of provider efforts to develop rapport and empathy with patients and expressed enthusiasm at the potential for new decision support tools to improve shared decision making in obesity and bariatric care. He urged providers to identify novel strategies to ensure that patients classified with clinically severe obesity and related morbidities are informed of the most appropriate treatments available to them.
“I am so very proud of and inspired by our growth in obesity research in the past six years," Sarwer says. "Given the scope of the obesity problem in North Philadelphia, across the United States, and throughout the world, it is humbling to be among the world’s leading groups in understanding the development of obesity, identifying impactful strategies to help people manage their weight and health, and creating prevention programs to reverse the growth of obesity in future generations.”