Dr. Ron Davis, AMA President

Stemming an Epidemic

Continuing Efforts to Turn the Tide on Obesity

CINDY SANDERS

People living at a healthy weight in the Southeast are in a clear minority.



A generation ago, less than 10 percent of those in the region would have been classified as “obese.” Today, one-third of the southeastern population is clinically defined as having a body mass index (BMI) of 30 or more, making it one of the heaviest regions in the country. When the issue is extended to include those considered to be “overweight,” the percentages climb sky high.



Of course, the Southeast isn’t alone in its struggle to eat healthier and move more. The 2003-04 National Health and Nutrition Examination Survey (NHANES) found that 66.3 percent of Americans are classified as overweight (BMI of 25-29.9) or obese (BMI of 30 or greater).



Approximately 34 percent of the adult population — more than twice that of the Healthy People 2010 goal — is now defined as clinically obese. And the issue isn’t limited to adults.



Children and adolescents are also struggling to maintain healthy weights. Comparing NHANES data from the 1988-94 survey to the more recent 2003-04 data collection, overweight children aged 2 to 5 increased from 7.2 to 13.9 percent. For those aged 6 to 11, the increase was from 11 to 19 percent, and overweight adolescents aged 12 to 19 increased from 11 to 17 percent.



With the nation’s expanding girth comes the growing, evidence-based medical concern that patients are at an increased risk for heart disease, hypertension, type 2 diabetes, cancer, stroke, and osteoarthritis among other conditions. Finding a way to turn the tide on this epidemic, however, has proven to be particularly frustrating for physicians and public health officials.



“Healthy People 2010,” the nation’s prevention agenda, set a goal that 60 percent of the adult population would be at a healthy weight with a BMI between 18.5 and 24.9, only 15 percent of adults would be categorized as obese, and that no more than 5 percent of children and adolescents aged 6 to 19 would be classified as overweight.



When asked if it was a possibility that America would reach the Healthy People 2010 goals in a mere two years, Dr. William H. Dietz, emphatically stated: “We’re not going to be anywhere close.”



As director of the Division of Nutrition, Physical Activity and Obesity for the Centers for Disease Control and Prevention, Dietz, a board-certified pediatrician and expert on nutrition and weight, is on the front lines of the ongoing battle to change the American culture.



In an otherwise bleak landscape, Dietz did find one potential bright spot.



“As of 2004, it looked as though the prevalence had increased in children, adolescents and men. In women, between 1999 and 2004, the levels had stayed flat, which makes me hopeful that although we haven’t turned the corner with women, we may be at the corner,” he said.



Dietz explained the reason this was a hopeful sign is because women tend to be early adopters of health behaviors and also act as the gatekeepers for the home, which should ultimately impact the health of children and spouses.



A new CDC report, released in late November 2007, confirmed there was no significant change in obesity prevalence for 2005-06. There appears to have been a leveling off in women’s rates since 1999. Men, who have seen an increase inobesity rates between 1999 and 2006, also leveled off over the past two years. 



Still, with more than 72 million Americans considered obese, Dietz, like other public health officials, recognizes it will take a true cultural shift to make any real headway in the nation’s attitude toward nutrition and exercise. Some of the barriers to change identified by the U.S. Department of Health and Human Services in their 2004 Progress Review include:

• We live in an environment of abundant food and portion sizes.

• With genetic, metabolic, behavioral, cultural, environmental and socioeconomic factors all impacting weight, reversing the current trends will require a concerted effort by all sectors of society.

• The amount of advertising dollars devoted to encouraging people to eat large portions of nutritionally bankrupt food far exceeds the dollars spent on making healthy choices … although this is beginning to change with fast food restaurants such as Subway® and McDonald’s® touting healthier options.

• The public is confused by fad diets and programs all promising quick results.

• Technology has engineered activity out of our daily lives.

• Most school systems don’t require daily physical education classes at all grade levels.

• There is a lack of acceptance of obesity as a disease by a large portion of the public, healthcare providers and third-party payers … this, too, is beginning to change as more payers are including discounts to health clubs or paying for other preventative measures, and more providers are monitoring patients and voicing concerns about weight shifts.

While healthcare providers are becoming more willing to discuss diet and exercise with patients, the approach needs to be refined in some cases, as weight is such an emotionally charged topic for many patients.



Dietz referenced a study that looked at the reaction of patients to certain weight-related words by Thomas A. Wadden, PhD, an NIH-funded professor of psychology and psychiatry at the University of Pennsylvania School of Medicine whose principal research is on the treatment of obesity. Wadden found that terms like “obese” and “big” had very negative connotations but that “overweight” was a pretty neutral term and “increased BMI” was acceptable.



“We have to recognize there is a difference in how we talk about the problem in society and how we talk to patients,” Dietz noted. “The first important piece is this has to be viewed as a behavioral problem that exists in a broader context.”



He continued, “A provider must realize their counseling needs to address the contextual framework in which a patient lives in addition to the patient’s behavior.”



Dietz pointed out that it doesn’t do much good to say ‘get more physical activity into your schedule’ if the facilities or resources don’t exist in a patient’s neighborhood.



He also believes the framework in which care is provided needs to be changed.



“The current paradigm doesn’t work when 30 percent of the adults and 18 percent of the children and adolescents are obese,” Dietz stated.



This past spring, Dietz was the primary author of “Health Plans’ Role in Preventing Overweight in Children and Adolescents” (Health Affairs, March/April 2007), in which he calls for the application of what amounts to a chronic care model to address the nation’s weight problem. The paper looks at a number of innovative initiatives by health plans designed to address the issue of overweight children and adolescents. Dietz and his co-authors call for U.S. health plans to embrace evidence-based, behavioral change strategies by directly intervening in medical settings and by supporting environmental modifications where children live, study and play. Although the paper was directed to interventions among minors, Dietz believes similar strategies might have some impact on adults, as well.



“This is not a problem that’s going to be solved by a piece here and a piece there,” Dietz concluded. “It’s going to take a comprehensive, multisectored approach if we’re going to be successful.”







Resources for Providers



The CDC and other federal agencies have put together a number of resources to assist providers in working with patients on reaching and maintaining healthy weights.

• From the CDC’s main page on obesity (www.cdc.gov/nccdphp/dnpa/obesity), providers can access a number of guidelines and evidence-based research. Click on “Resources” in the left-hand column for a list of educational topics (including the latest dietary guidelines for Americans) designed for patients and providers, alike.

• Clinical guidelines for the identification, evaluation and treatment of overweight and obesity are available through the National Heart, Lung and Blood Institute in cooperation with the National Institute of Diabetes and Digestive and Kidney Diseases at www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm

• Nutrition resources for health professionals are found at www.cdc.gov/nccdphp/dnpa/nutrition/health_professionals and include the “Weight Management Research to Practice” series with practical application on topics such as breastfeeding’s impact on pediatric overweight, using fruits and vegetables to manage weight and the impact of portion sizes and sugary beverages.

• The Healthy People 2010 site, www.healthypeople.gov, includes goals and progress reviews for numerous topics ranging from specific health conditions to access to care to behavioral modifications including tobacco usage and nutrition and overweight.

January 2008

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