AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. July 2004, Volume 6, Number 7.

Journal Discussion

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The Physician's Role in Preventing Obesity

Physicians have a duty to treat and prevent obesity by discussing nutrition and physical activity with their patients.

Christian J. Krautkramer

Manson JE, Skerrett PJ,

Greenland P, VanItallie TB. The escalating pandemics of obesity and sedentary lifestyle. A call to action for clinicians. Arch Intern Med. 2004;164:249-58.

Curiously, we live in a time when Americans find themselves busier than ever before and yet fatter than ever before. Our society has placed emphasis on getting things done more quickly and efficiently, often at the expense of a lifestyle that includes routine physical exertion. Exercise-related activities are not a priority or even of secondary concern for many. I can sympathize; I was a busy fat kid. Sports and exercise-related activities were neither discouraged nor encouraged in my household. In part, my lack of participation in sports or fitness activities was the choice of someone who, not naturally athletic, didn't desire the embarrassment that can come from playing with others who are more skilled. The other reason is that I was talented in other ways—musically, academically, creatively—and outlets to foster their development took priority, leaving little time for more athletic pursuits. While my pediatrician discussed with me the problems of being overweight, we never plotted out a concrete course for weight loss.

The inclusion of exercise in my life occurred in college, where for the first time I had athletic friends—people who were both academically focused and understood the importance of a vigorous lifestyle. Today, in my mid-20s, my daily routine includes working out, which, among its benefits, has included increased energy and improved body-image. While my body type and metabolism ensure I'll never be traditionally thin, I've enjoyed significant weight loss, muscle development, and improvement in endurance. Unfortunately, many children, young adults, and even older adults lack role models to encourage physical activities that would achieve both immediate and long-term health benefits.

JoAnn Manson and her colleagues understand that my situation was not unique: millions of Americans are currently part of what they frame as a "pandemic of excess weight and inactivity," linked to severe morbidity, over 300,000 premature deaths, and a shocking $90 billion dollars in direct health care costs [1]. These statistics are similar to another public health concern: smoking [2]. But while the war against tobacco use has had many champions in medicine, the war on obesity and sedentary lifestyle hasn't received the same attention, despite similar health costs. In fact, recent data has suggested that obesity is associated with more chronic disorders and poorer health-related quality of life than tobacco or alcohol use [3]. As illustrated by my own experience, powerful social trends can help drive and maintain lifestyle choices that marginalize the importance of daily exercise. Manson et al, however, believe that physicians can play a meaningful role in significantly reducing weight-related morbidity and mortality through weight-loss counseling and active-lifestyle encouragement during the clinical encounter.

The National Health and Nutrition Examination Survey, which uses body mass index (BMI) to calculate the number of overweight and obese Americans, concludes that 131 million Americans are overweight or obese, with a 3-fold increase in Americans' obesity since the early 1960s [4]. Among children, nearly 16 percent can be classified as overweight, a 4-fold increase since 1963 [5]. The Behavioral Risk Factor Surveillance System (BRFSS) suggests that only 25 percent of adult Americans meet the current recommendation of 30 minutes of leisure-time physical activity daily, and nearly one-third engage in no activity at all [6,7]. The authors contend these trends begin in childhood—less school time today is devoted to physical education classes, fewer children are walking or riding bikes to school and play activities, and more leisure time is devoted to passive, technology-driven activities like video games, television, and computers [8-10]. This increase in obesity, reinforced by childhood habits, increases co-morbidity for severe health risks later in life, particularly cardiovascular disease and type 2 diabetes, but also other diseases including osteoarthritis, osteoporosis, and cancers of the colon and breast. And, as previously mentioned, sedentary lifestyle and obesity carry significant economic burdens. Data analysis in 1994 and 1995 suggest that obesity and inactivity account for 9.4 percent of all money spent on health care, similar to costs attributed to tobacco use [11]. Not unique to our country, obesity-related costs in other developed nations such as France, Australia, Canada, and the Netherlands are also significant, ranging from 2 percent to 5 percent of total health care costs [12-13].

The relationship between being overweight due to inactive lifestyle and severe, chronic health concerns, according to Manson et al, is significant enough to prompt clinicians, and in particular physicians, to devote part of their patient interaction to discussing the necessity of physical activity and good nutrition as elements of a healthy lifestyle. To do this, clinicians must be able to identify high-risk patients, feel comfortable and empowered to broach the subject of weight control and physical activity, offer behavioral strategies that lead to effective and long-lasting improvements in these variables, and understand the indications for considering pharmacologic or surgical management. Survey results suggest physicians fail miserably to make substantive dialogue on weight loss part of their clinical interaction. BRFSS data from the late 1990s show that fewer than half of obese individuals received advice to lose weight in their last office visit [14]. Further, only 34 percent of adults who had seen a physician in the prior year reported counseling on physical activity as part of a healthy life [15]. Why does counseling on exercise and nutrition fail so often to be part of a routine doctor's visit? Manson et al, offer 3 primary reasons. First is failure to cover these topics as part of medical education. A second reason is that physicians, already pressured by managed care management to see more patients daily but devote less time to them individually, are cutting corners in their clinical encounters [16]. Finally, there may be simply a failure to recognize that this type of counseling is truly under a physician's purview.

However, the Office of the US Surgeon General and the National Heart, Lung and Blood Institute recommend that all physicians engage their patients in a dialogue on their risk for obesity and how good nutrition and regular exercise can prevent related health concerns [17-18]. Included in this encounter should be a measurement of BMI. If a patient's BMI is greater or equal to 25, with a waistline of 40 inches or greater in male patients and 35 inches or greater in female patients, the physician and patient should construct a plan for weight loss. Manson et al suggest that if a patient is receptive to losing weight, a target loss of 5 percent to 10 percent below baseline weight should be set (with a loss of between 0.5 and 2 pounds a week), achieved through both a reduction in caloric intake and increased exercise. This dialogue is particularly important for patients with a BMI of 30 or greater (or BMI of 27 or greater with comorbidities for serious, chronic disease) since their risk for coronary heart disease and premature mortality is doubled and their risk for type 2 diabetes is tripled. Patients with BMI greater than 35, classified as severely obese, may want to consider bariatric surgery if all other weight-loss options, including pharmacotherapy, have been exhausted.

Finally, Manson et al note that just as positive words are important for patients already engaging in an active lifestyle, so too is positive encouragement of currently sedentary patients. Physicians should write them "prescriptions" for 30 minutes of activity each day—from walking to ballroom dancing to biking. The prescriptions should be accompanied with the warning that diligence is needed for maintainable results but that even modest weight reduction leads to improved health outcomes, including improved blood pressure and lipid levels, increased energy, and improved self-esteem. Encouragement must be coupled with a clear understanding that it is unacceptable to engage in a sedentary lifestyle—that a major key to a long, healthy life is daily physical activity. Implicit in this model is what may be a new task for physicians—message repetition. Patients may be need to be encouraged or reminded of the necessity of daily exercise several times, perhaps even outside the context of an office visit, in order for this lifestyle change to become a permanent, necessary part of their lives.

Questions for Discussion

  1. Using "pandemic" in this article's title suggests that obesity and sedentary lifestyle constitute a broad public health problem, akin to an infectious disease outbreak where everyone is at risk. Is this an appropriate use of the word "pandemic?" Should obesity and sedentary lifestyle be treated as a national health emergency?
  2. Assuming that obesity and sedentary lifestyle are threats to our public health, are physicians obligated to lobby for a positive policy environment to combat obesity (including, but not limited to, advocating for reducing subsidies for the production of corn-based sweeteners, increasing economic incentives for weight loss, restrictions on junk food/fast food advertisement geared toward youth akin to tobacco advertisement restrictions)?
  3. The authors suggest that physicians offer positive reinforcement and communicate with patients to increase the chances for long-term weight loss. If treating a patient for obesity and sedentary lifestyle requires more frequent communication than conventional treatments, is it part of a physician's responsibility to extend the scope of his or her practice to include emailing, calling, or use of other techniques to "keep them from falling off the wagon?"


References

  1. Manson JE, Skerrett PJ, Greenland P, VanItallie TB. The escalating pandemics of obesity and sedentary lifestyle. A call to action for clinicians. Arch Intern Med. 2004;164:249-258.
  2. Shephard R. Whistler 2001: A Health Canada/ CDC conference on communicating physical activity and health messages: science into practice. Am J Prev Med. 2002;23:221-225.
  3. Sturm R, Wells KB. Does obesity contribute as much to morbidity as poverty or smoking? Public Health. 2001;115:229-235.
  4. Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among US adults, 1999-2000. JAMA. 2002;288:1723-1727.
  5. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents,1999-2000. JAMA. 2002;288:1728-1732.
  6. Physical activity trends—United States, 1990-1998. MMWR Morb Mortal Wkly Rep. 2001;50: 166-169. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5009a3.htm Accessed July 7, 2004.
  7. US Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: US Government Printing Office; 2000.
  8. Lowry R, Wechsler H, Kann L, Collins JL. Recent trends in participation in physical education among US high school students. J Sch Health. 2001;71:145-152.
  9. US Department of Transportation. Nationwide Personal Transportation Survey. Washington, DC: Federal Highway Administration; 1997.
  10. Rideout VJ, Foehr UG, Roberts DF, Brodie M. Kids and Media at the New Millennium: A Comprehensive National Analysis of Children's Media Use. Menlo Park, Calif: Kaiser Family Foundation; 1999.
  11. MacKenzie TD, Bartecchi CE, Schrier RW. The human costs of tobacco use, 2. N Engl J Med. 1994;330:975-980.
  12. World Health Organization. Obesity: Preventing and Managing the Global Epidemic—Report of a WHO Consultation on Obesity, 3-5 June 1997. Geneva, Switzerland: World Health Organization; 1998.
  13. Katzmarzyk PT, Gledhill N, Shephard RJ. The economic burden of physical inactivity in Canada. CMAJ. 2000;163:1435-1440.
  14. Sciamanna CN, Tate DF, Lang W, Wing RR. Who reports receiving advice to lose weight? Results from a multistate survey. Arch Intern Med. 2000; 160:2334-2339.
  15. Wee CC, McCarthy EP, Davis RB, Phillips RS. Physician counseling about exercise. JAMA. 1999;282:1583-1588.
  16. Kottke TE, Brekke ML, Solberg LI. Making "time" for preventive services. Mayo Clin Proc. 1993; 68:785-791.
  17. National Institutes of Health, National Heart, Lung, and Blood Institute, Obesity Education Initiative. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Available at: http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.htm. Accessed June 28, 2003.
  18. The Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity. Rockville, Md: US Dept of Health and Human Services, Public Health Service, Office of the Surgeon General; 2001.

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