What to do about the epidemic of obesity?

We are the first generation in the history of mankind that can have what we want to eat, when we want it and in unlimited quantities. In addition, the food we eat is largely the rich and fat-loaded "holiday" food which our family ancestors reserved to special family and religious celebrations that occurred only a few times each year but we now have it weekly or daily.

"Health is influenced by factors in five domains - genetics, social circumstances, environmental exposures, behavioral patterns, and health care. When it comes to reducing early deaths, medical care has a relatively minor role. Even if the entire U.S. population had access to excellent medical care - which it does not - only a small fraction of these deaths could be prevented. The single greatest opportunity to improve health and reduce premature deaths lies in personal behavior. In fact, behavioral causes account for nearly 40% of all deaths in the United States. Although there has been disagreement over the actual number of deaths that can be attributed to obesity and physical inactivity combined, it is clear that this pair of factors and smoking are the top two behavioral causes of premature death."

Steven A. Schroeder, M.D. We Can Do Better - Improving the Health of the American People NEJM Volume 357:1221-1228, September 20,2007.

The domain of genetics is a comfortable one because it implies culpability beyond our control. Time and again we have had families in our care where the children using health lifestyles overcame their "bad genes" as evidenced by their older relatives so we need to be prepared to help them. The AAFP Americans in Motion brings just such assistance to our practices.

Quoting from the AAFP AIM Web site, Ready, Set, FIT! is a school-based educational program that teaches third and fourth graders about the importance of fitness through a partnership between the American Academy of Family Physicians' fitness initiative, Americans In Motion (AIM) and Scholastic. Through a partnership between the American Academy of Family Physicians' fitness initiative, Americans In Motion (AIM) and Scholastic, Ready, Set, FIT! offers in-class lessons and take-home activities aimed at encouraging kids to be active, eat smart and feel good.

The AAFP - AIM has developed materials for improvement in our office practices including the AIM to Change Toolkit which contains resources to help us interact with patients as well as patient education materials including the AIM Fitness Inventory for patients to complete and use it to gauge their current level of fitness and their readiness to change. "Tips for Healthy Children and Families Poster Pack " is free and contains helpful posters for our offices. Finally, to help us in new ways of addressing the AIM goals in our office, the AIM Group Visits Guide is a guide to conducting and getting paid for group visits for patients with chronic conditions affected by overweight and obesity.

Environmental and social circumstances are also important. Studies have shown that the availability of high quality food is limited in areas of lower socioeconomic impact because of the lack of quality grocery stores in those areas. Look at your home communities. In most medium towns and larger, the availability of fresh healthy good for families who want to live healthier lives is made more difficult by the lack of groceries. Convenience stores and fast food outlets that often are the sole providers of food to those neighborhoods replace these.

The evolution of the nuclear family also impacts food choices. Both working parents may lead to latch key kids who are unsupervised in after-school nutrition. When the family reconstitutes for the evening meal, it is often prepared outside the home, brought home and is cased in Styrofoam. These are personal values and perceived family needs that definitely impact the family approach to obesity.

Behavioral influences are known to lead to overeating. After World War II, a plump child was a healthy child. We were the recipients of the "clean up your plate" patterning. We are fortunately seeing changes there due to the efforts of family physicians and pediatricians stressing early childhood nutrition to young moms who hear and heed. There are however consistent uses of food as gratification/environmental control. Crying babies get fed - breast, bottle or pacifier. Good children get candy. Ice cream treats are welcome in later years.

Adult interactions (such as church events, dating and medical staff meetings) are all associated with lots of "good" food. Watch the evening TV and be amazed at the pizza and hamburger ads (usually interspaced with the DTC drug ads and the lawyer ads looking for class action suits against the DTC drugs). We are constantly bombarded by Madison Avenue temptations of oral satiety.

As I was on the treadmill this morning (yes, a frightening image but true) watching the brain numbing TV, there came on two different public service announcements of kids turning down high fat, high calorie snacks at play and at movies with cool music and cartoons in the background. They closed with a young child loudly proclaiming "DON'T SUPERSIZE ME!!" What a wonderful image to put in the minds of our kids and grandkids. Effecting programming and clear cut messaging aimed at kids has helped with tobacco - it's use in obesity can do nothing less than help.

Health care approaches require a consistent, continuous, comprehensive,compassionate (The Values of Family Medicine) approach to identification of the above noted confounding factors. A trusted physician "family member" offers advice, education and encouragement for modification of the above behaviors. We have been successful at least in part in the area of tobacco use. The AAFP Tar Wars program stands out as a campaign of education for children and early intervention. We have not been completely successful. As long as product is available, there will be incomplete success.

Taking the "Tar Wars" model, family physicians may want to start a "Fat Fight" or such similar education campaign. We are seen, known and respected in our community.

Advocacy for physical education in our schools, removal of high caloric, high fat snack and drink machines, healthy diets at school and home may take generations but we must begin somewhere. However, as Schroeder says the success with tobacco doesn't predict easy success with obesity.

Food is necessary to life and is very legally available. Governmental agencies have not been very success at changing individual "freedoms" and until the public health and costs are recognized - just like with motorcycle helmets - these food freedoms and their sellers will be hard to change. Just like politics, these battles need to be fought at the local level. Societal pressures just like with tobacco are our best hope. We need to help.

The AAFP can help with programs like AIM and with legislative testimony supporting a strong family medicine base for a new health care plan with adequate payment for on-going continuity based comprehensive care.

As a scientist, I am excited about the future in this area of weight and wellness. We have developing knowledge of the science of weight gain, obesity and GI physiology. The studies of hormone homeostasis concerning Ghrelin Leptin and GLP-1 continue to excite me that we may be able to help patients with new and exciting (non stimulant) therapies.

I have had the enjoyment of sharing patient successes with exenatide with weight losses of up to 60 pounds now sustained and with excellent diabetic control. I would hope that our academic colleagues and those involved in research networks would be participatory in this work. During these times of Pharma-bashing, we need to remember how the lives of many have been changed with real pharmacological advances.

Who would have thought that ten years ago, a failed antihypertensive named sildenafil would have had such an impact on the intimate lives of our patients? The future can be very exciting and who knows.

One place the AAFP can play a role is in the personal health and well being of family physicians. Too often, we are the worst role models. We treat our patient's stress in highly stressful practices. We counsel dietary wellness just before we gulp down a quick high calorie meal. We encourage time off for vacations and wellness as we haven't taken a vacation in years. We measure our quality of care by the number we see in a day and the length of hours we work without sleep. Things have to change.

Modeling is important and best practices must be recognized. Family medicine needs to be practiced in a setting that provides support for time off and coverage. Teams of providers need to be encouraged that permit the physician to do what they do best - diagnosis and decision making - with pre-evaluation and post-care done by others under supervision. We need to model the lives we prescribe for our patients.

Restructuring of the health care system, active modification of medical liability to a state of reality where the patient is protected and the provider treated fairly, support for physicians in need and provision of a work environment that provides expedited information flow with best practices/evidence support quickly and easily available should be our goals. If not for us, lets do it for those students.

I have probably gone on too long. Remember the adage by H. L. Mencken, (Prejudices: Second Series, 1920)

"There is always a well-known solution to every human problem--neat, plausible, and wrong. "

How do we improve medical student to family medicine resident recruitment?

I have seen class after class come into our medical schools bright and eager to practice the excitement of the specialty of family medicine only to come out four years later entering limited practice specialty residencies.

Individuals in internal medicine training delay their decision to avoid general medicine only by a few years since 80 percent of their pipeline in residency ends up in a sub-specialty.

Why does this happen?

In early August, I ate lunch at the AAFP Resident and Student Conference with two delightful students - one from a southeastern state university medical school and one from a metropolitan mid Atlantic city. - The one from the southeast is considering family medicine, pediatrics and psychiatry as career choices. She had taken a year off between her second and third year to get away from the stress of worrying about the debt - yes the debt - not the curriculum - not the call - the debt. She was at that point $80,000 in debt and wanted to figure out if it was worth going on. Fortunately, for the thousands she will touch and help in the future, she decided it was worth it and she came back.

The other student was more up-front. She goes to a private medical school and her borrowings yearly average $75,000 a year. Her debt for her medical education will equal a house purchase. She is enthusiastic and excited and sees the investment as worth it.

To quote James Carville, "it's the economy, stupid."

Students coming out of medical school see years of debt repayment (the southeastern student figures she will be paying off her educational notes for the rest of her life.) vs. life in a "doughnut specialty" with high procedural payments able to give them a comfortable life and pay off a mountain of debt at the same time.

We used to worry about the academic bigotry and specialty racism endemic in the non-family medicine faculty in our academic centers. I'm not seeing that as much recently. It may still be a factor but the quality of our graduates turned out in difficult times and the excellence of our faculties hopefully have put that to rest. Sure, there are some screamers around but they are recognized for what they are - insecure within their own persona as physicians and people. To again quote James Carville, "it's the economy, stupid!"


We must reform how family physicians are paid for their services. Pay family physicians 2/3 of what an orthopedist, a dermatologist or a radiologist makes and you won't have enough slots out there to train eager smart young medical students who are passionate to be family physicians. There are typically two types of services provided - episodic illness (usually structural problems) and ongoing continuous, comprehensive, coordinating, compassionate, caring for life and wellness for life care (apply these to any other specialty and they will come up wanting).

Unfortunately, we in the US have been boxed into the single type of payment - episodic payment for illness-based care for our services. Take out my appendix and follow me for 6 weeks and get paid a global fee. Deliver me from my mother, protect me by immunization, suture my lacerations, counsel me about sexuality, manage my diabetes, control my hypertension, diagnose my chest pain, counsel me when I find drugs in my kids room, advise me about the risks and benefits of prescription drugs, care for me during my surgeries, find my cancer and hold my hand as I die (The Value of Family Medicine) and get paid a pittance for each episode - having to fight a system that does not recognize the value of comprehensive life long care.

That care needs to be paid as a comprehensive service. Paul Ellwood and the Jackson Hole Group were right with the HMO concept. Call it now the RUC proposal for the Medical Home. Call it concierge medicine. Comprehensive payment on an ongoing basis for comprehensive ongoing care is long overdue. The AAFP needs to have a seat at the table leading up to the changes in the American medical system. If not for us, then for those two young students and their patients. I promised it to them.