Public Health Commentary - April 2005
By H. Paul Cooper, MA; Molly Gee, MEd, RD; Lindsay Rodgers, RD; and Armin D. Weinberg, PhD
In January, then-U.S. Health and Human Services Secretary Tommy G. Thompson and Agriculture Secretary Ann M. Veneman released the Dietary Guidelines for Americans 2005 , the federal government's science-based advice to promote health and reduce risk of chronic diseases through nutrition and physical activity. They place stronger emphasis on reducing calorie intake and increasing physical activity. They can be found at www.healthierus.gov/dietaryguidelines.
Over the years, many physicians have been frustrated by their inability to help patients deal with the problem of weight control. With one-third of Texas school-aged children and two-thirds of Texas adults classified as overweight or obese, it is clear our state is in the midst of an epidemic. Trends indicate that by 2040, 75 percent of Texas adults might be overweight or obese. According to the Texas Department of State Health Services (DSHS), $4.21 billion, or 6.3 percent, of adult health care expenditures in Texas in 2001 were for overweight- and obesity-associated illnesses. Unless evidence-based prevention and treatment strategies are successfully implemented, the health and economic costs of this disease may reach insurmountable proportions.
A survey conducted during September and October of 2004 by the Texas Medical Association's Physician Oncology Education Program (POEP) provides additional insight into the physician's role in addressing the obesity problem.
POEP surveyed a random sample of 631 primary care specialists involved in direct patient care on issues related to managing overweight and obese patients. The survey was part of the ongoing "Talk Back Against Cancer" survey project funded by the Texas Cancer Council that the POEP uses to develop resources to address the oncology education needs of Texas physicians. While POEP was specifically interested in learning whether primary care physicians routinely discuss cancer risks with their overweight and obese patients, most of the survey questions focused on more general weight-management issues.
The 13 percent of sampled physicians who responded to the survey did not differ by distribution of medical specialty, practice setting, year of graduation from medical school, age, or gender from those who did not respond. An 88-percent majority of this representative group of 80 respondents indicated they have an increasing number of overweight and obese patients. No one reported that the proportion of such patients was declining. Most respondents reported discussing the weight-related health risks of cardiovascular disease, type 2 diabetes, metabolic syndrome, hypertension, hyperlipidemia, stroke, sleep apnea, and joint problems with an overweight or obese patient during the previous12 months. But only one in three said they discussed weight-related cancer risks with an overweight or obese patient during the same period.
Ninety-five percent of respondents said they recommended treatment that combined diet and exercise to an overweight or obese patient during the past 12 months. During the previous year, 85 percent had referred an overweight or obese patient to a dietitian, and 70 percent had referred such a patient to a gym or exercise program. They said the most important barriers for their patients to maintaining a healthy weight were psychological factors, sociocultural factors, and the inconvenience of maintaining a healthy weight.
When asked what they would find most useful to their practice to address this problem, the most frequently selected resource was educational materials to share with patients, followed by information on how treatment could be covered by private insurance or Medicare. Unfortunately, only 38 percent of respondents were familiar with the 1998 Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: Evidence Report released by the National Heart, Lung, and Blood Institute's Obesity Education Initiative in cooperation with the National Institute of Diabetes and Digestive and Kidney Diseases. Some objectives behind the clinical guidelines were to alert practitioners to the growing problem of obesity and its associated health risks and provide patient educational materials.
With rising medical costs and increasing patient loads, physicians find themselves with less time to spend with each patient. While it may be unrealistic in most cases to expect physicians to become involved in the details of a patient's weight-management efforts, they can initiate the following first steps toward evidence-based care.
First, physicians can encourage prevention by informing their patients about the new government Dietary Guidelines for Americans 2005 and reminding them of the latest scientific evidence concerning the health risks associated with obesity, including heightened risks for various cancers. The evidence linking obesity and cancer with certain site-specific cancers is clearly established. Informing overweight and obese patients of their increased risks for colon, kidney, gallbladder, cervical, endometrial, ovarian, or breast cancer may provide just the push they need to take action on controlling their weight.
Second, physicians can use available resources like the 1998 Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: Evidence Report to enhance their assessment and treatment of patients. The results of the recent POEP physician survey indicate that such resources are underutilized.
Third, they can refer overweight and obese patients to dietitians, other health care support staff, and exercise professionals who can provide the level of weight-management assistance that cannot be delivered in the typical physician-patient interaction. By taking these three initial steps with their patients, physicians can play a critical role in stemming the growing epidemic of overweight and obesity.
Dr. Weinberg, Molly Gee, and H. Paul Cooper are on theBaylor College of Medicine staff. Dr. Weinberg chairs the Physician Oncology Education Program Trends Committee. Ms. Gee and Ms. Rodgers are consultants to the committee.
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