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THE PHYSICIAN AND SPORTSMEDICINE - VOL 32 - NO. 6 - JUNE 2004


Survey Suggests a Decline in Obesity Counseling

Physicians Analyze Reasons

Despite rising obesity rates, fewer healthcare professionals are counseling patients about weight loss, according to recent findings from the Centers for Disease Control and Prevention (CDC). In a presentation in April at the annual conference of the CDC's Epidemic Intelligence Service, Omer Abid, MD, PhD, an epidemic intelligence service officer with the CDC, reported the trend.

The data come from the Behavioral Risk Factor Surveillance System, a state-based telephone survey of adults ages 18 and older. The question asked was: "In the past 12 months, has a doctor, nurse, or other health professional given you advice about your weight?" Among the respondents who were categorized as obese according to their body mass index (BMI equal or greater than 30.0 kg/m2), 42% in 1994 had been advised by a health professional to lose weight. In 2000, however, the percent advised to lose weight decreased to 40%. The decrease is statistically significant, Abid says. Declines were greatest in women, younger (18 to 29) and older (70 and up) age-groups, non-Hispanic white people, those with some college education, those with BMIs between 30 and 34.9, and those not diagnosed with diabetes.

When examining the characteristics of patients who were counseled to lose weight in 2000, the odds of being counseled increased with educational level, poorer health status, diabetic diagnosis, and rising BMI.

The researchers also explored whether patients attempted to lose weight after having been counseled by a healthcare professional. In the 2000 survey, 59% of patients who were not counseled attempted to lose weight; however, 80% of those who did receive counseling attempted to lose weight.

In his conclusion, Abid said that his group did not expect the overall decline in counseling of obese patients. Researchers expected a possible increase in weight loss counseling because of heightened awareness of obesity problems. Obesity rates were rising during the study period, and the National Institutes of Health in 1998 had published clinical guidelines on the diagnosis and treatment of obesity.1

Abid said the study suggests that there are barriers to counseling obese patients, which may include lack of training and resources, lack of reimbursement, and competing priorities in the limited office visit. Solutions could include incorporating a system that flags for counseling patients who have BMIs in the obese range. He said reimbursements for referrals to a dietician or weight loss counselor may also help reverse current trends.

THE PHYSICIAN AND SPORTSMEDICINE sought feedback on the study findings from several physicians who are experts on weight control or activity promotion or whose practices involve counseling patients about weight loss issues. Here is a sampling of their comments.

Earl Carstensen, MD, family physician in Aurora, Colorado, who focuses on nutritional and preventive care

What factors do you think contribute to the CDC's findings?

There is no or minimal payment for obesity counseling, yet gastric bypass surgery is covered for many patients. An American Academy of Family Physicians survey suggests a physician prejudice that obesity equates to a lack of discipline. Many patients express desire to lose weight but deny, even passionately, a relation to present eating and physical activity habits.

How can some of these barriers be overcome?

Clearly, a team focus is required, but a team will not succeed unless the patient recognizes the need for lifelong daily eating and physical activity changes. Patients can change their body composition. The "how" is simple, just not easy. I equate it to learning any new skill.

Douglas B. McKeag, MD, MS, professor and chair of the department of family medicine at Indiana University School of Medicine in Indianapolis

What factors do you think contribute to the CDC's findings?

There are a lot of unanswered questions. Obesity is the "sexy" topic now and has overtaken smoking as the number one cause of death. This problem has been around for a long time, but no one pays for this or educates for this. No one pays me to sit down and talk to patients about weight loss, but the system will pay for bariatric surgery. It's a preventive medicine issue, and medicine simply doesn't have its act together.

How can some of these barriers be overcome?

Obviously, reimbursement would help. Tools that might be effective include weight charts for physicians' offices and information on calorie content of common foods that physicians can provide to patients. Exercise should be a required part of any secondary weight loss program; however, for many reasons, it's still extremely difficult to encourage people who live in ghettos to be more active.

William O. Roberts, MD, president of the American College of Sports Medicine and associate professor in the department of family practice and community health at the University of Minnesota in St Paul

Is the downward trend a significant concern?

Both numbers are not good. I am concerned that the number is dropping, but even more concerned that the number is not close to 100%.

What factors do you think contribute to the CDC's findings?

Lack of reimbursement for weight counseling is probably a significant factor. The basic training is there in medical schools, but all residencies may not put this together in a format that is easily transferred to patient care in a time efficient manner that can be worked into office routines.

How can some of these barriers be overcome?

It's a variation on "Build it, and they will come": Reimburse it, and it will get mentioned. I'd also suggest increased education for medical students, residents, and practicing physicians.

Roy J. Shephard, MD, PhD, DPE, professor emeritus of applied physiology on the Faculty of Physical Education and Health at the University of Toronto

What factors do you think contribute to the CDC's findings?

Most physicians would make time if the financial rewards were sufficient. Some doctors, who enhance fee schedules by giving hormonal injections of doubtful efficacy, make a full-time practice of treating obese patients. But there is not a lot of money to be made out of effective counseling, and there is no allowance at all in the regular examination schedule. A second issue is the misleading information circulated by a number of dieticians regarding differing metabolic set points, which are often used as an excuse for obesity. A third issue is undoubtedly lack of education in the areas of exercise and nutrition. These topics still feature too rarely in medical school curricula.

Finally, many physicians are themselves overweight, and thus in no great position to offer advice on the control of obesity.

How can some of these barriers be overcome?

Given that physicians are unlikely to be paid their anticipated hourly rate for counseling, the best answer probably is to pass this task to paramedical professionals who are content with a lower income and, in many cases, are better prepared to offer advice on exercise and nutrition. This is best accomplished within a health center where a number of different medical and paramedical professionals work in close cooperation. It is important that the advice to lose weight be seen as given by the physician, with the detailed counseling offered at his or her suggestion, as several surveys have shown that physician advice is still a potent factor influencing patient behavior.

Paul D. Thompson, MD, director of preventive cardiology at Hartford Hospital in Hartford, Connecticut

What factors do you think contribute to the CDC's findings?

These are a great concern. If a physician does not mention a problem to a patient, the patient often hears what he or she wants to hear, which is that the problem is not a concern to the physician, so the patient should not worry about it, either. Doctors still have a lot of respect in society, so their encouragement and advice to work on weight loss still carries weight (pun intended).

Doctors do not deal with things they don't think they can change. It's too frustrating and makes them feel even more powerless. No one needs more negativity with all the financial constraints, lawsuits, and other issues. I am convinced that doctors have failed so often to get folks to lose weight that many have given up trying or even bringing up the topic. If the doctor brings it up, the patient will ask for advice, and the doctor does not have good solutions because weight loss is hard. Also, the doctors who do intervene do so too late after the patient is already very overweight.

How can some of these barriers be overcome?

Physicians need to do simple things: Weigh everyone, ask about exercise, encourage exercise, and discourage weight gain, even in patients who are just mildly overweight. No one gets obese immediately. It's a creepy disease, with the emphasis on the creep.

Doctors must get involved. Obesity affects almost every bodily system. It's much better to prevent the osteoarthritis, hypertension, diabetes, and heart disease before they occur.

Lisa Schnirring
Minneapolis

REFERENCES

  1. National Heart, Lung and Blood Institute, National Institute of Diabetes and Digestive and Kidney Diseases: Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: the evidence report. National Heart, Lung and Blood Institute, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, Government Printing Office, NIH publ no 98-4083, 1998

Field Notes

Team Physician Reflections on Pat Tillman

Though professional football player Pat Tillman's death in the remote mountains of Afghanistan captured wide public interest, those who worked with him during his football career—including team physicians—certainly felt a more personal sense of loss.

According to published reports, Tillman opted out of a $3.6 million contract with the Arizona Cardinals in 2002 when he enlisted, along with his brother Kevin (a minor league baseball player), in the US Army. Tillman ducked the limelight when he made the decision to join the military. He was killed in action on April 22 near the Pakistan border. Media reports have said that his unit was ambushed by al-Qaeda and Taliban fighters.

Among the several memorial services that were held for Tillman included a private gathering at Arizona State University (ASU) for his college football colleagues. He was linebacker for the Sun Devils from 1994 to 1997. Among those in attendance was Brent S.E. Rich, MD, ATC, who was ASU team physician during those years. "There were over 75 former players, coaches, administrators, and others who were there to pay their respects," Rich says.

Rich, a family practice physician at ASU's student health service and who also has a private sports medicine practice, says he doesn't recall Tillman sustaining any major sports injuries while at ASU. "He played with bruises and mild injuries, but I believe that he dished out more than he received," he says. Rich and other team physicians recall how Tillman would seek them out for more than just their medical expertise. "One of our favorite memories of Pat is when we would be at lunch, and he would come by and ask to sit with us," Rich says. "He didn't want to talk about football issues, but about life, philosophy, politics, and just 'stuff.'"

Tillman, who was known as an individualist, competed in triathlons and marathons and often opted to ride his bike rather than drive a car. "He definitely was unique, talented, a patriot, and a beautiful person, and I'm proud to call him my friend," Rich says. "His decisions should inspire all of us to be grateful for what we have and stand up for what we believe." According to an article in the May 3 issue of Sports Illustrated, the last well-known professional athlete to die in military service was Buffalo Bills lineman Bob Kalsu in 1970.


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