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Obesity is the easiest diagnosis to make, says Robert Kushner, MD, medical director of the Wellness Institute at Northwestern Memorial Hospital in Chicago. All it takes is measuring height and weight.
Despite a 2003 statement from the U.S. Preventive Services Task Force (USPSTF) calling for health care professionals to screen for obesity, "it is currently under the radar screens of physicians," Kushner says. "The news is, doctors need to step up to the plate."
Kushner delivered his remarks during the American Diabetes Association's 20th Annual Southern Regional Conference, held in Orlando, Fla., May 26–29. This year's sessions focused on diabetes, obesity, and cardiovascular disease.
Kushner cites a recent survey of 255 overweight and obese patients treated by 18 primary care physicians that shows obesity is consistently underdiagnosed and undertreated.1 Patients were more likely to receive education about weight loss than specific behavioral advice on how to lose weight, the researchers conclude. And physicians were more likely to provide weight-control advice to patients with obesity-related comorbidities than to overweight patients who did not have additional risk factors.
Few doctors are trained to treat and manage obesity, Kushner says. Other barriers to incorporating obesity care into practice are a "don't ask, don't tell" strategy that may reflect physicians' lack of confidence in weight-loss treatments. If they do offer recommendations that are unsuccessful, both patient and doctor can quickly develop a sense of futility and avoid the problem entirely, Kushner says. In addition, obesity is uncommonly a patient's chief complaint, and most providers remain accustomed to an acute care approach to treatment.
To overcome these obstacles, clinicians need a plan that recognizes obesity as a hub of related problems and not just something to mention during the last minutes of an office visit, he says.
Kushner reminds primary care providers of a valuable book published by the North American Association for the Study of Obesity and the National Heart, Lung, and Blood Institute. The Practical Guide to the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults provides detailed steps to help practitioners assess and manage obesity as a chronic disease. It includes practical information on nutrition therapy, physical activity, and behavior therapy, as well as guidance about drug and surgical treatments.
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While tackling overweight and obesity may be a daunting venture, Kushner urges providers to put it in the context of more complicated medical achievements.
"Physicians have taken on and overcome much more challenging tasks" than identifying and treating obesity, he says.
PRESCRIBING PHYSICAL ACTIVITY
In another session, Neil F. Gordon, MD, PhD, MPH, medical director of the Center for Heart Disease Prevention in Savannah, Ga., served up a litany of challenges, rationales, strategies, and results related to prescribing exercise as one component of a comprehensive cardiovascular disease (CVD) risk-reduction program.
One major challenge comes from 2002 USPSTF data that show only 25% of Americans achieve the levels of physical activity recommended in Healthy People 2010, Gordon says. Although some trials suggest that primary care counseling can promote increases in physical activity, the task force concludes there is insufficient evidence proving the overall effectiveness and feasibility of physical activity counseling by clinicians in primary care settings.2
But the rationale for promoting physical activity interventions comes from a number of prospective studies that demonstrate a decreased incidence of coronary heart disease (CHD) in fit individuals, says Gordon, a professor of medicine at Emory University in Atlanta.
Gordon points to a 1987 meta-analysis of 43 studies that finds the relative risk of inactivity to be similar in magnitude to that of hypertension, hypercholesterolemia, and smoking.3 According to the researchers, these findings suggest that CHD prevention programs should promote regular physical activity as heartily as they do blood pressure control, dietary change to lower cholesterol, and smoking cessation.
"We now know... exercise has a favorable impact on every risk factor that is amenable to intervention," Gordon says. It lowers triglycerides and LDL cholesterol, offsets the effects of smoking (and smokers who exercise are more likely to quit), lowers both systolic and diastolic blood pressure 5–10 mmHg, and decreases blood glucose in patients with diabetes, he says.
"When we prescribe exercise, we do have to consider the potential adverse effects for those with diabetes," Gordon says.
He advises providers to be aware of the risks for some diabetes patients of excessive blood pressure increases during exercise and low blood pressure afterward, in addition to the risks of cardiac dysfunction, arrhythmia, and sudden death due to ischemic heart disease, which is often silent.
Gordon also notes that exercise can worsen blood glucose control in some patients and may cause hypoglycemia in patients on insulin therapy or oral agents. Providers and patients should also pay attention to the development of any foot ulcers, especially in the presence of neuropathy.
"Though I stress: exercise is very safe and effective for
diabetics," Gordon says. "It's vitally important for physicians to
emphasize physical activity. If they don't, it is unlikely patients will
participate." 
How to Promote Physical Activity
How much exercise a physician prescribes should be based on a patient's needs, ability, and level of motivation. Paul Estabrooks, PhD, and colleagues offer guidance that can be broken down to five As:
Assess the patient's current level of physical activity, physical abilities, and beliefs and knowledge about exercise.
Advise the patient about the health benefits and risks of activity, and provide guidance on the right amount, intensity, and type.
Agree to collaborate with the patient to develop a personalized action plan and to set specific goals based on the patient's interest and confidence.
Assist the patient in developing strategies to overcome barriers and identify opportunities for community and social support.
Arrange for follow-up assessments through visits, phone calls, and mailed reminders.
Source: Estabrooks PA, Glasgow RE, Dzewaltowski DA: Physical activity promotion through primary care. JAMA 289: 2913–2916, 2003.
Footnotes
The Practical Guide to the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults is available online at www.nhlbi.nih.gov/guidelines/obesity/practgde.htm.
Clinical Management of Obesity: With Special Attention to Type 2 Diabetes is a professional toolkit available from the American Diabetes Association (ADA). It includes a continuing education monograph, a CD-ROM provider interview outlining five key steps to achieving weight loss, and printer-friendly patient materials. For more information, visit www.diabetes.org.
Hot off the press from the American College of Sports Medicine: ACSM's Guidelines for Exercise Testing and Prescription (seventh edition). This manual summarizes recommended procedures for exercise testing and exercise prescription in healthy and diseased individuals, with current public health and clinical information and research-based recommendations. Available online at www.exrx.net/Store/Other/ACSMGuidelinesExTestingRx.html. Other books available at www.acsm.org/publications/books.htm:
ACSM's Exercise Management for Persons With Chronic Diseases and Disabilities (second edition) emphasizes practical application more than scientific theory. Each chapter is written by an expert in the field and contains a case report featuring real people's symptoms, medical histories, lab results, and exercise test scores, along with exercise programming and follow-up information.
ACSM's Action Plan for Diabetes helps providers and patients fight diabetes with fitness by presenting an exercise-based plan that can be tailored to an individual's needs.
References
2. U.S. Preventive Services Task Force: Behavioral counseling in
primary care to promote physical activity: Recommendation and rationale.Ann Intern Med
137:205–207, 2002.
3. Powell KE, Thompson PD, Caspersen CJ, et al.: Physical activity and the incidence of coronary heart disease. Annu Rev Public Health 8: 253–287, 1987.[Medline]
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