The prevalence of overweight and obesity in the United States has soared during the past two decades. In fact, according to a report recently released by the surgeon general, the prevalence of obesity among adults grew from 13.4 percent in 1980 to 34.3 percent in 2008. The prevalence among children grew from 5 percent to 17 percent during the same period.
"The Surgeon General's Vision for a Healthy and Fit Nation, 2010"(www.surgeongeneral.gov) also found that obesity contributes to an estimated 112,000 preventable deaths a year. It is inextricably linked to many serious health conditions, including high blood pressure, high cholesterol, type 2 diabetes, heart disease, stroke, gallbladder disease, sleep apnea and respiratory problems, as well as to endometrial, breast, prostate and colon cancers.
In addition, the report notes that children with a high body mass index, or BMI, are more likely to develop diabetes and high blood pressure and to carry unhealthy levels of fats and other lipids. Moreover, obese children often become obese adults.
Such findings have led to an increased focus on overweight and obesity in the United States, as well as an increased focus on living healthier.
And family physicians are on the front line in this particular battle. According to several analysts interviewed by AAFP News Now, FPs are in an ideal position to arrest and even reverse skyrocketing obesity rates because of the unique role they play in the U.S. health care system.
The family physician's office is the "place where patients' care is coordinated and their problem list is elucidated," giving FPs a "huge role in educating their patients," says former U.S. Surgeon General Richard Carmona, M.D., the health and wellness chair of the Strategies to Overcome and Prevent, or STOP, Obesity Alliance(www.stopobesityalliance.org).
Carmona notes that family physicians and other primary care health professionals understand the challenges faced by overweight and obese patients. They are among the most trusted of any health care professional, and unlike other physicians and health care providers, they take care of patients from cradle to grave, positioning them to employ a long-term, patient-centered approach to obesity and weight management issues, says Carmona.
According to FP Paul Jarris, M.D., M.B.A., executive director of the Association of State and Territorial Health Officials, much of what is driving the nation's obesity epidemic takes place outside of the realm of health care. This has added a level of complexity to the prevention and treatment of overweight and obesity, while forcing family physicians to think well beyond traditional office visits when managing patients with these problems.
Jarris contends that dramatic increases in obesity rates largely are a result of processed food and built environments, which encourage more food consumption and discourage exercise. "We know human evolution does not change within a generation, so we know that it is not humans who have changed," says Jarris. "Therefore, it really has to be the environment that has changed around the humans that is causing this (epidemic)."
For example, more people are eating meals outside of the home, and many of these meals are higher in calories, sodium and fat, he says. And even when meals are consumed within the home, they tend to contain more processed food rather than being cooked from scratch because people want their meals to be fast and convenient, according to Jarris. In addition, he notes, food portions have increased significantly, adding to people's caloric intake and fueling the nation's obesity epidemic.
At the same time, people are not as physically active as they used to be. This largely is a result of built environments that discourage walking or bike riding, says Jarris.
In addition, the widespread adoption of multiple technological innovations in homes, workplaces and schools also has made people more sedentary, according to the surgeon general's report.
Family physicians must take these factors into consideration when treating patients who are overweight or obese. In fact, family physicians interviewed by AAFP News Now stressed the importance of partnering with patients to make small but significant changes that eventually will result in large shifts in patient behavior.
"Small changes that are very detail-specific tend to be easier for patients than saying, 'Listen, you have to change your whole diet and you have to exercise six times a week,'" says Lenard Lesser, M.D., of Los Angeles, a family physician and Robert Wood Johnson Clinical Scholar at the University of California, Los Angeles.
"Those step-by-step things tend to build your relationship with your patients and tend to work (better) than telling them to make one huge, big change in their whole life," says Lesser, who is an authority on the linkages between obesity and food and nutrition environments.
One of the first questions Lesser asks his patients who are overweight or obese is whether they drink soda, because that can be a major source of calories. "I work with them to see how we can cut down on the soda, switching to diet sodas, things like that," says Lesser.
Lesser also works with patients who live in unsafe neighborhoods that are not conducive to exercise and with patients who reside in so-called food deserts -- areas lacking grocery stores that carry fresh fruit, vegetables and meat.
"Like anything in family medicine, it is about working with what the patient has and figuring out what is the healthiest thing they can get," says Lesser. For example, if a patient lives in an unsafe neighborhood, Lesser will talk with that patient about exercises that can be done in the home. He also broaches the idea of forming walking groups within the neighborhood to enhance safety when walking.
When working with patients who are overweight or obese, Lesser says he first assesses where the patient is in life, what he or she is willing to do, and what opportunities exist for the patient to make small, helpful changes in his or her life.
Casey Kirkhart, D.O., who practices at the Saban Free Clinic in Los Angeles, follows a similar approach. Physicians need to provide the space for patients to come up with solutions on their own, he says.
Of all the things that FPs do, encouraging healthy lifestyles requires the most patient-centered approach, he notes. Change is hard for these patients, says Kirkhart. "I guess I am not having (patients) change on a particular thing so much as I want them to change their mindset about how they can be healthier in general."
In taking a patient-centered approach, Kirkhart allows patients to identify obstacles that may be preventing them from eating appropriately or exercising. One of the main goals is to let patients "generate the changes they want to make," says Kirkhart.
"If they can walk once a week -- when they (previously) walked no times per week -- for them, that is 100 percent success," he says. "That is improvement over what they have done."
Kirkhart often dispenses exercise prescriptions, putting exercise goals the patient has identified in writing. "I sign it, I put my stamp on it so it looks like any other prescription," he says. In nearly every instance, patients keep the prescriptions, using them as a reminder of their exercise goals.
Like other family physicians, Kirkhart treats patients who live in food deserts and in unsafe neighborhoods, and he has to individually assess what patients have available to them.
For example, says Kirkhart, most patients have a choice when it comes to bread. "I try to get them to try wheat bread instead of white bread or brown rice instead of white rice."
Kirkhart also is planning to ask a local farmers' market to visit the Saban clinic to familiarize patients with the concept of the farmers' market and the fruits and vegetables that are available.
"There is a farmers' market almost every day of the week in Los Angeles," says Kirkhart. "So it is just a matter of letting the patients know that it exists and that they have access to these locally grown fruits and vegetables."