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Monday Nov 20, 2017

Just the Facts: Can Patient Education Help in Obesity Crisis?

It has been nearly 30 years since "Weird Al" Yankovic won a Grammy with Fat, his parody of Michael Jackson's Bad. It was easy at the time for some to laugh at Yankovic, in full makeup and fat suit for the music video, because obesity wasn't yet a national epidemic in 1988.

[doctor's hands speaking with patient]

Adult obesity wasn't even tracked in every state, and for the 39 states that did collect data in 1989, none had an obesity rate above 14 percent. Just 10 years later, however, Colorado was the only state with a prevalence lower than 20 percent. When the CDC recently released updated statistics, 47 states had obesity rates of at least 25 percent.

You might recall that Yankovic's song ends with him replacing Jackson's "Who's bad?" line with the question, "Who's fat?"

The answer, today, is too many of us (although we have moved away from saying that three-letter word that begins with "F"). Nearly 20 percent of U.S. children and more than one-third of adults are struggling with obesity. The problem is so bad that roughly one-fourth of our young people aren't fit to serve in the military.(www.cdc.gov)

As the numbers get worse year after year, family physicians might feel like we can't put a dent in this crisis. So, what can we do, and what should we do?

The thing that struck me as I read the CDC report was the correlation between education and obesity. As the level of education rises, the rate of obesity drops. Adults who didn't finish high school had the highest level of obesity at 35.5 percent, followed by high school graduates (32.3 percent), those who attended college (31 percent) and college graduates (22.2 percent).

One of the most important things we do as family physicians is provide education and information to help patients make smart choices about their health. Obesity is a multifaceted problem, and issues such as access to fresh foods, income and having a safe place to exercise are significant barriers for some people, but if we provide the facts about how weight affects health, can we help patients and parents pick better paths?

I recently had one parent tell me that her oldest child had been an overweight kid who just "grew out of it," and she was not worried about her younger, overweight child because she assumed that child also would grow out of it. I told her that family history wasn't necessarily going to repeat itself, and an abundance of research has shown that children and teens with obesity are far more likely to become adults with obesity. The consequences are alarming, including increased risk for heart disease, diabetes, certain cancers and all-cause mortality.(www.cdc.gov)

That got her attention.

If we get their attention, will they follow through? We've all had patients who come in wanting to lose 20 pounds quickly because their reunion, wedding or beach vacation is approaching. But are they ready to change habits, and do they have the willpower to sustain those changes after those special events? The motivation of the event ends when the date passes. If they know the harsh facts mentioned above, will that make a difference?

Honestly, it won't for some. But for those we reach, the results can be life-changing.

Success in this area isn't easy or fast. It's not like a cortisone injection that allows the patient who walks in with a limp to walk out with reduced pain. At some point, nutrition, physical activity and weight loss are up to the patient. However, as a family physician I also recognize that for many, there are systematic and structural barriers that prevent the healthy choice from being the easy choice. Food deserts, built environments and policies that regulate access to resources that support healthy eating and active living play a significant role in the lives of many who struggle with obesity. The AAFP's new Center for Diversity and Health Equity was established with the goal of assisting family physicians in reducing these barriers for our patients.

The dilemma is similar to another epidemic we face in our communities -- opioid abuse. That problem, too, is growing, and physicians are frustrated. Again, education can help patients understand why lower doses and shorter prescriptions are vital to preventing the disease of addiction from taking root in the first place.

A year ago, due to the epidemic of opioid overdoses and deaths, I began having patients for whom I prescribe opioids for more than 10 days sign a medication agreement. (I like this term better than "narcotic contract.") I recently had an elderly patient ask why she had to sign such an agreement to continue accessing these medications from my practice. After all, I have prescribed them for her for years without any signs of misuse on her part. I informed her of the opioid-related death statistics in our county. As her physician, I know that she has a neighborhood boy who helps her with chores, some of which are in her home. He has access to her bathroom when necessary. Also, her grandchildren come to her home after school and stay until their parents get off work. In situations like these, unsecured medications could easily end up in a punch bowl at a teenage party.

As physicians, we know that most teens who abuse prescription drugs get them from a friend or relative, but this was news to my patient. Now she understands how a population health issue happening outside of her home can reach inside it. She readily signed the agreement, and now keeps her pills in a locked box.

I am trying to wean all my patients who are on long-term opioids off these medications. This meets with resistance initially, as I am sure it does for many physicians. But again, once I explain our community's life-threatening epidemic and the lack of evidence for efficacy for chronic pain -- and, most importantly, assure them that we will work together to find safer modalities for their pain -- they are at least willing to try.

A long time ago, I realized that my most important job as a primary care physician was not diagnosis or treatment but education. A healthy lifestyle prevents or treats most of our ailments, and when patients understand how they can participate in their care, they are able to lessen their symptoms and loss of control. This approach applies to issues like obesity and opioid abuse, which can leave both physicians and patients feeling helpless at times. Education, however, can put patients on the right path to helping themselves.

Alan Schwartzstein, M.D., is speaker of the AAFP Congress of Delegates.

Posted at 03:40PM Nov 20, 2017 by Alan Schwartzstein, M.D.

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