CHICAGO — Primary care physicians are well positioned to help reverse the trends of physical inactivity and obesity in all age groups, according to fitness authorities at the Uniformed Services University of the Health Sciences in Bethesda, Md.
Physicians should motivate their patients to engage in regular appropriate exercise and the sooner, the better, Col. Brian K. Unwin, MC, USA, told the annual meeting the American Academy of Family Physicians.
It's estimated that 66% of adults are overweight or obese and one-half of children and adolescents are overweight or are at risk of becoming overweight, according to the Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health (Epidemiol. Rev. 2007;29:6–28). By 2015, three-quarters of adults will be overweight or obese, and 41% of children and adolescents will be obese, according to the latest projections.
The optimal time to address the issue with patients is before they reach the age of 18, said Maj. Anthony Beutler, MC, USA, chief of the USU Injury Prevention Research Laboratory. Dr. Beutler and Dr. Unwin are with the university's F. Edward Hébert School of Medicine.
“In certain populations, up to 45% of new diabetes mellitus cases in young people aged 10–19 years are type 2 disease,” Dr. Beutler said.
A quarter of obese preschoolers become obese adults, and the remaining three-quarters become normal-weight adults. However, 80% of obese 14-year-olds remain obese as adults, and nearly three-fourths of obese children who lose weight will maintain that loss as adults.
“We have an opportunity to make important changes before this window closes … between the ages of 14 and 18 years,” Dr. Beutler said. “Getting the adults to change can be tremendously difficult and time consuming, but we can look for people who are ready to change or are contemplating being more active. But with children, we can make a huge difference that has a lasting effect.”
Many physicians are reluctant to address behavior modification with their patients, often viewing the effort as too time consuming or ineffective, or they may lack confidence in their ability to change patient behavior.
Dr. Beutler and Dr. Unwin recommend that physicians adopt an action plan first published in 2006 by researchers at the University of California San Francisco (J. Am. Board Med. 2006;19:215–23). The same researchers subsequently applied their plan to helping patients adopt more healthful behaviors (Clinical Diabetes 2007;25:66–70).
They emphasized physician-patient collaboration in working toward behavior modification. “After a patient has agreed on a general goal, the patient and caregivers negotiate a specific action plan to assist in goal attainment,” they wrote. For example, if the goal is to get more exercise, the plan may include specific aerobic and resistance training targets. The action plan is available at www.familymedicine.medschool.ucsf.edu/community_service/actionPlan.aspx
To increase the likelihood that patients will succeed, they're asked to rate the importance of behavior change and exercise, then to estimate how confident they are that they can carry out their action plan, using a scale of 0–10. Doubts about either can be allayed through further discussions that may extend over several patient visits.
Dr. Beutler prefers to think of physical activity more in terms of fitness rather than solely as a means of losing weight. “There's strong evidence from several studies that being fit reduces the risk of disease no matter what your body mass index is,” he said.
Before your patient heads for the gym, be sure to assess his baseline fitness so that he can proceed without becoming discouraged or suffering pain or injury, Dr. Beutler explained, adding that the American College of Sports Medicine offers useful guidelines for determining risk and setting reasonable goals.
Healthy men under age 45 and women younger than 55 fall into the low-risk category. Risk increases with age, and also with conditions such as diabetes and cardiac disease. Having an HDL-cholesterol level of 60 mg/dL tends to counteract risk factors, he said.
“Low-risk people don't need a treadmill test before starting to exercise and high-risk patients should always be screened. Testing also is suggested for moderate-risk individuals who plan a vigorous exercise routine. “Always screen patients with signs or symptoms of cardiac disease or known metabolic or pulmonary disease,” he said.
In the case of sedentary elderly patients, in whom obesity is much less of an issue, more stress is placed on preserving function and independence, Dr. Unwin said.
The elite or competitive athlete has a high aerobic capacity that begins to decline with age, but always remains higher than that of the average weekend warrior, whose break in aerobic capacity occurs earlier and more dramatically, he explained. “But if we add exercise to the equation, we can help that older person regain a lot of that capacity and start a new curve.”