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.

It's imperative that physicians motivate

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 Hebert 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, and that's a very scary statistic," Dr. Beutler said, adding that body mass index at age 18 is a stronger predictor for diabetes mellitus risk than at any other age.

One-fourth of obese preschoolers become obese adults, while 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 explained, adding that it's important to work with the child's parents and encourage them to make exercise a family affair.

"Getting the adults to change can be tremendously difficult and time consuming, but one thing we can do is to 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," Dr. Beutler said in an interview.

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). Those same researchers subsequently applied their plan to helping patients adopt more healthful behaviors (Clinical Diabetes 2007;25:66-70).

The authors 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," the researchers wrote. For example, if the goal is to get more exercise, the action 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, adding that excess mortality is highest among those who are unfit and obese.

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.

High-risk patients should be screened, and testing is recommended 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," Dr. Beutler said.

In addition to aerobics, exercise regimens need to include resistance training, static and dynamic balance exercises, and stretching to maintain flexibility. "Sedentary people lose 20%-40% of their muscle mass, or about 6% a decade past age 20. However, walking and running don't address this, and that's why strength-building resistance training is so important as we age," Dr. Unwin said.

In sedentary elderly patients, more stress is placed on preserving function and independence, Dr. Unwin said.

By applying herself to a regular workout program, a sedentary older adult can increase her strength anywhere from 40% to 150%, "and that can mean the difference between walking to the mailbox and going up and down stairs, or going directly to assisted living ... or to a nursing home," he said.

"If we can get our patients to maintain their strength as well as their aerobic capacity, hopefully we'll be intervening on these geriatric syndromes of falls, frailty, sarcopenia, and loss of function," he concluded.

BY BRUCE K. DIXON

Chicago Bureau