You already know the statistics. Sixty percent of Americans are either overweight or obese. The prevalence of obesity today is twice what it was 20 years ago. Studies by Kaiser Permanente show that the nation’s rate of overweight children has tripled over the same period.

By almost every measurement, Texas outweighs the national average. Nearly one of every four Texans is obese. A recent study by the University of Texas School of Public Health concludes that 40 percent of the state’s fourth-graders are overweight.

When Men’s Fitness published its most recent annual ranking of the country’s 25 fattest cities, guess which state claimed six spots on the list? You got it — Texas, our Texas. Bad news for the state, but good news for Houston, which no longer tops the list. After clenching the magazine’s fattest city title five out of the last seven years, Houston slipped to No. 2. Dallas, San Antonio, Fort Worth and Arlington join Houston in the top 10 and El Paso comes in at 24.

Detroit assumed the top spot in the magazine’s list, but if you ask the Centers for Disease Control and Prevention, the country’s fattest city is San Antonio, with 31 percent of its adult population weighing in as obese. Fernando Guerra, M.D., director of the San Antonio Metropolitan Health District says the problem has reached epidemic proportions.

“This happened before our very eyes, as physicians and as those who had been caring for these populations over time,” Guerra says. “I really think that in our daily work as we see patients … we need to use every opportunity when we interact with a patient or a family to talk about staying healthy and about good nutrition, and recognize when an individual is overweight and call that to their attention.”

Like the rest of the state, San Antonio’s incidence of obesity is a problem for all sectors of society but the numbers trend higher for poor populations and for Hispanic and African Americans. Guerra says part of the reason for this is a cultural tradition that associates being overweight with being healthy. “As I was telling a mother the other day whose baby weighed 7 pounds at birth and weighed 21 pounds at 4 months of age … that is totally out of line with what one wants to see in assuring good health for an infant,” Guerra says. “But her response to that was that’s the way they’ve been brought up.”

The obvious culprits share in the blame for all of those extra pounds: sedentary lifestyles centered around a set of screens, be they televisions or computers; the fast food culture and its super-size mentality; America’s penchant for high-calorie thirst quenchers. But Guerra also points to some less obvious factors that may lead to increased obesity. Poor design of urban communities leave many people without sidewalks or safe crossings at busy intersections, which discourages walking and makes automobiles and busses a necessity. In poor neighborhoods and around housing projects, playgrounds are often so dilapidated and unsafe that parents are unwilling to send their kids out to play. “They run the risk of swings that are broken, or slides that have sharp edges, or broken glass and a lot of debris on the playground. The communities are unfortunately, in many instances, not so conducive to promoting many of these different activities that lead to good health.”

For Texas Commissioner of Health Eduardo Sanchez, M.D., the community is the key to battling what he says is one of the greatest threats to the future of Texas. The issue has become his top priority and his attention is evident. Obesity headlines seem to lead state newspapers regularly as of late, and most quote statements made by the commissioner at various local events. Sanchez has been busy on the issue campaign trail speaking about the cost and danger of obesity from every lectern he can find.

Super-sized burgers and super-sized fries are the new weapons of mass destruction,” he told the crowd at AAFP’s Conference on Patient Education held in San Antonio last November.

Sanchez says a conservative estimate of obesity’s annual cost to Texas is $10 billion. When then U.S. Surgeon General David Satcher issued a call to action on obesity in 2001, he said the condition played a part in 300,000 deaths a year in America and cost the country over $117 billion per year. Sanchez says that number may be larger today, but his fear is what the epidemic will cost the country in another 10, 20 or 30 years.

Consider these figures. Texas Department of Health reports that 35 percent of school-age children are overweight. We know that children who are overweight at age 12 have a 75-percent chance of being overweight as adults. Today in Texas, 61 percent of adults are considered to be overweight or obese. When these adults were children, less than 15 percent of them were considered overweight.

Not worried yet? Here are some more numbers. The medical costs of an obese 30-year-old are the same as those of a normal-weight 50-year-old. And what about mortality? “Some of the things we know are associated with obesity include cardiovascular disease — the number one cause of death — some forms of cancer, which is the number two cause of death in our state,” Sanchez says. “The likelihood of stroke can be made worse by obesity. That’s the number three cause of death in our state. And then there’s type 2 diabetes and among some of our subpopulations and in some regions of our state … that’s the number four cause of death.”

As TFP readers know, type 2 diabetes was once commonly referred to as adult onset diabetes and instances of children developing the disease were rare, but that has changed. Each year more children are diagnosed with type 2 diabetes, and after someone has had the disease for 20 or 25 years, Sanchez says a number of complications can occur, like kidney failure, blindness and cardiovascular disease. Physicians could find themselves caring for a population of 40-year-olds who are needing the kinds of interventions that are now mostly reserved for patients in their 60s, 70s and 80s — amputations and dialysis, to name a couple.

“What I am concerned about is the consequences of the rising prevalence of obesity superimposed on a population that is growing older … that we may reach a point where we may not have the resources to address the demand for medical intervention or medical attention,” Sanchez says.

That forecast may be preventable, but the commissioner believes it will take a new definition of public health. Sanchez envisions an integration of public health activity in communities, in schools and in work places that would partner with the medical community. He talks about community health workers who could act as support and intermediaries for medical clinics, exercise and nutrition programs based at schools and churches and recreation centers.

But to begin this redefinition would require the state to spend more money on public health, and extra money is not something the state government has lying around. At any rate, Sanchez says the first step to averting the possible fiscal disaster of outgrowing our health care system is to make certain that everyone knows the links between obesity and the list of diseases it is association with. In a newspaper editorial last August, he wrote that he isn’t sure everyone understands those connections. The second step is to concentrate attention on school-age children while they are developing nutrition and exercise habits that could stay with them throughout their lives.

Texas policymakers have tried a number of ways to get children to exercise more and to eat healthier. In 2001, Sen. Jane Nelson (R-Flower Mound) had success passing a requirement that students in kindergarten through sixth grade must participate in some sort of daily physical activity. Before the measure became law, there was no requirement that students below ninth grade had to take a gym class. The CDC had released a report stating that the percentage of students taking daily physical education had dropped from 42 percent in 1991 to 27 percent in 1997.

Sen. Nelson’s bill, S.B. 19, was designed with a school-based program in mind, the Coordinated Approach to Child Health, or CATCH, which was developed by the University of Texas School of Public Health at Houston. The program contains four components including a classroom curriculum, physical education, nutrition through school food service and family partnership. For schools implementing the program, teachers and staff receive training on the components. The program has shown measures of success, but its implementation costs money — about $2,500 per school or about $10 million for a statewide rollout, — and so far the state has been unwilling to put up the cash.

Tom Waggoner, director of fine arts with the Texas Education Agency, is charged with the responsibilities of the agency’s department of health and physical education while the agency looks to fill the position after a recent retirement. Waggoner says that while he’s not an expert on the subject of physical health, he was involved in the changes brought by Sen. Nelson’s bill and in his opinion, schools are complying. “Many school districts, I’m sure, are meeting the time requirements through physical education class, but many other school districts are meeting the time requirements through other means, such as a structured recess or even something like the movement component in music class.”

The father of a second-grader, Waggoner says physical activity in school is of course an important component in kids’ health, but in his opinion, the area to focus attention today is in the cafeteria. School nutrition, or the lack thereof, was a hot topic in the last regular session of the Legislature and it will definitely pop up again in the next. The main bill on point was S.B. 474 by Sen. Eddie Lucio, Jr., (D-Brownsville) and Rep. Jaime Capelo (D-Corpus Christi). What began as a very ambitious bill was somewhat watered down by the time it was signed by the governor.

“First off, I’d like to tell you that I introduced this bill on children’s nutrition … because of my deep concern over obesity and its related diseases in the youngest of Texans,” Lucio says. The original bill would have addressed the nutritional value of school cafeteria fare and placed several restrictions on student access to vending machines. It also called for the formation of a commission of officials and experts on nutrition to assist the TEA.

“I felt very strongly that these guidelines would have helped children on the road to making better choices regarding food and prevented them from having a 20-ounce bottle of soda with a bag of potato chips as a meal choice,” Lucio says, adding that the bill came up against “immense opposition” from school administrators and the soft drink industry. “Some that were afraid of losing revenues from vending machines discouraged the members of the Senate Education Committee from supporting this legislation.”

What eventually passed was a bill calling for the appointment of a joint interim committee to conduct a study, the findings of which could play very heavily in what happens in the next regular session. The committee will consist of the commissioners of education, public health and agriculture, legislators from the House and the Senate and six public members of various related positions. The committee is charged to “determine the nutritional content and quality of foods and beverages served to public school children,” including all of the foods kids have access to that compete with what is offered in the cafeteria. Another charge is to study the impact of obesity, both psychological and physiological, on public school children. The study will assess the value of a universal breakfast and lunch program and it is also supposed to conduct a comprehensive evaluation of school contracts relating to competitive foods and vending machines.

Rep. Capelo, who chairs the House Public Health Committee, says he is both pleased and disappointed with the passage of S.B. 474 — he’s glad something passed though he had hoped for more than a study. “But I will tell you this,” he says, “the session before last when I filed the first vending machine bill, I couldn’t even get a hearing in committee … I know we are making tremendous progress in educating our fellow members in the need for the state to be involved with obesity and with diabetes.”

Capelo is optimistic that the work being done in the public health committee combined with the joint study will produce a finite list of changes in state policy that can make a difference in obesity and diabetes in Texas. “If you take a look at our state policy right now, we really don’t have any state policy with the true goal or intent to fight obesity.” Like Dr. Sanchez, Capelo believes helping Texans shed some pounds is a matter of self-preservation for the state when considering health care costs in 10 or 20 years. “If we think the budget problems we’re having now are critical, just the cost of diabetes and obesity will overwhelm the Medicaid program beyond anything the state will be able to generate in terms of tax dollars,” he says.

While legislative restrictions on foods of minimum nutritional value (FMNV) may become law in the future, Susan Combs isn’t waiting around. She’s the commissioner of the Texas Department of Agriculture and this summer, Gov. Perry petitioned the U.S. Department of Agriculture to change the receiving agency for the federal school breakfast and lunch funds from the TEA to the TDA. That move gave Combs the power to set food policy for public schools, and she did — quickly. The revised policy issued July 28, 2003, banned FMNVs from all public elementary schools and denied access to all FMNVs during meal times at public middle schools.

“We make [children] go to school by state law,” Combs says. “They are required to, and by golly, it’s sort of like ‘do no harm.’ While you’re in our custody, we should be doing you no harm, and I think we were doing harm.”

FMNVs comprise foods like cotton candy, chips, carbonated soft drinks and chewing gum. A ban on these in many cases means a ban on vending machines, and vending machines make money for school districts. Needless to say, the health care community has been thrilled with TDA’s action and some of the school districts have not.

The ban doesn’t apply to sport drinks, juices, water and the like, and Lucio, Capelo and Combs are all quick to say that they don’t want to see vending machines completely removed from all schools. They just want to see a healthier selection offered. The problem is that many of the school contracts have commission structures that favor the least healthy choices. To shed some light on the situation, TDA has posted on their Web site (www.agr.state.tx.us) a spreadsheet comparing the details of contracts held by more than three quarters of the state’s school districts. The contracts are worth an estimated $54 million to the school districts, but the districts also report that they are probably losing around $60 million in lost sales for their food service programs.

Could it be that schools can still amass the funds they need without lucrative vending machine contracts? Capelo and Combs think so. They both point to an Austin school district that they say has increased revenue from their food service program by serving healthier food. “I think what we have is a hesitancy to change the system that’s currently in place, but I think we’re going to be able to demonstrate that school districts will be able to maintain the money that they need to while doing good,” Capelo says.

During the legislative interim, the TAFP legislative team will continue to monitor developments and offer input to the joint interim committee studying obesity. Also, the Academy has volunteered to work with TDH in developing appropriate education for physicians regarding the treatment of obesity.

AAFP’s prescription for fitness

When the American Academy of Family Physicians met for its annual convention last fall, the association’s newly inducted president brought a bold message about the epidemic of obesity: “Let’s walk the talk!” In his address, Michael Fleming, M.D., of Shreveport, La., introduced the academy’s new 10-year public health initiative, Americans in Motion, or AIM, the first stage of which is an all-out push to get physicians to practice what they prescribe.

Now, Fleming is not a small fellow, so for him, leading this charge is not only a commitment for his term as president, it’s personal. “I expect a great deal from me,” he told the crowd. “I commit that when I stand here again next year to address you, there will have been a change. I will still be big in heart and big in the enthusiasm to serve you, but because of my commitment to AIM, there will be less of me to speak to you.

By December, Fleming had lost 19 pounds.

Through AIM, the AAFP Commission on Public Health is developing a set of tools to empower physicians to help their patients, families and communities fight obesity, but the first step is to get physicians to buy into the program, Fleming says. “I have always thought — and I can say this easier now — that it’s been a little disingenuous for me to tell a patient to lose weight and frankly I would see obese patients and they would tease. They would say, ‘You know, I want to keep you as my doctor because you can’t tell me to lose weight.’”

For Fleming, the dilemma is reminiscent of a scene from his past. His grandfather had heart disease. He was in the hospital after suffering a heart attack, the last he would have before he died. “His cardiologist came in the room and told my grandfather that he had to quit smoking,” Fleming says, “and then snubbed out his own cigarette.”

Fleming also remembers when his wife came to him without smiling and asked if he wanted to be around for his grandchildren. “We have four grandchildren now and she was very serious about that. That’s sort of why I did this.”

Fleming says the goal for AIM is to provide a “prescription for fitness” that will give patients specific guidance to combat obesity. The vision he describes for AIM involves a partnership between AAFP and individual communities. “I think we need to get it at the community level and then let the community levels coalesce into something larger.”

For now, the challenge has been put to family physicians. To participate in the challenge, click on the AIM link on the front page of AAFP’s Web site, www.aafp.org.

definitions

Terms of treatment

BMI (Body mass index)

Weight in kilograms divided by the square of height

in meters (kg/m2)

BMI conversion

Weight in pounds divided by the square of height

in inches (lbs/in2) multiplied by 703

WEB LINK

Online BMI calculators can be found on many health-related Web sites, like this one on the CDC site: 

www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htm.

Terms for adults

Overweight = BMI between 25 and 29.9

Obese = BMI of 30 and above

Terms for children

The definitions for children are different from those for adults because children grow in height as well as weight. In 2000, the CDC and the National Center for Health Statistics published BMI reference standards for children ages 2 to 20. The reference standards for age and gender can be found online:  www.cdc.gov/growthcharts/. 

NOTE: Texas Commissioner of Health Eduardo Sanchez, M.D., advocates the use of the terms “at risk for overweight” and “overweight” in place of “overweight” and “obesity” respectively when talking to and about children.

At risk for overweight = BMI at or above the 85th percentile to less than the 95th  percentile of the reference standards for age and gender

Overweight = BMI at or above the 95th percentile of the reference standards for age and gender

A Texas-sized fitness campaign

Gov. Perry has teamed up with a number of partners from across the state to launch The Texas Round Up, an initiative to encourage all Texans to incorporate daily physical activity and healthy choices into their lives.

The Texas Round Up is a statewide effort that provides a simple, low-cost, and goal-oriented approach to motivating Texans to get active. This incentive-based program, which launched in January 2004, is designed to get Texans moving at least 30 minutes a day five days a week.

As part of the Texas Round Up, Gov. Perry will be presenting the Governor’s Challenge, an effort to entice all Texans to get involved. The competition will be based on per capita participation in the Round Up program as well as the Texas-sized 10K event, April 17, 2004 in Austin. The city and/or region with the highest participation rate in the Round Up program will be awarded the Governor’s Cup and will be named “Fittest City/Region” in the state.

You can find more information about The Texas Round Up at www.texasroundup.org.

women and exercise
THE GYM: NOT JUST FOR HIM
One personal trainer’s take on what keeps women from working out
BY LYNN ADAMS

I think you know my friend. She has a high stress job. She is a mom. She is bright. Just another wonder-woman making her way through a busy, busy life. She is also carrying an extra 30, 40 or 50 pounds and is dancing too close to type II diabetes. Her cholesterol is edging higher and higher each year along with her blood pressure.

As her physician, you’ve had a couple of brief discussions about the weight, the dangers. But she has steadily gained weight over the past few years. You tell her, again “eat less and exercise more,” but you are not optimistic about any change. Neither is she.

My friend is not alone. According to a report from the U.S. Surgeon General:

• More than 60 percent of women do not engage in the recommended amount of exercise

• More than 25 percent of women do not exercise at all; and

• Lack of exercise is more common with women than men.

Numerous factors contribute to why women are less likely to exercise. One theory is that men may be more motivated to exercise due to fear of a sudden and fatal heart attack. Until recently it was accepted that women were not as likely to suffer from something as dramatic as an MI, and this may explain some of the difference between men’s and women’s willingness to exercise. Of course, now that cardiovascular disease is quickly becoming an equal-opportunity killer maybe women will become as motivated as men.

As your patients’ primary health information resource, you have a vital role in inspiring and educating women to lead healthier lifestyles and you need to be aware of why women resist exercise. The challenges you face in your roles as information source, monitor, inspector and inspirer are significant.

The level of shame reported by even slightly overweight women in our society can be difficult to grasp but should not be minimized. Let’s consider some very basic interpersonal dynamics — you male, she female. She is embarrassed to talk with you about medical issues much less her appearance and weight. Another scenario — you female, she female. Jealousy and competition can sometimes inhibit a meaningful discussion between you and your patient. Your appearance can also influence the discussion. If you appear fit, your patient may think you don’t understand the challenges she faces and that you are judging her. Of course, if you are not in the best of shape, you may have a credibility problem. Age differences can also get in the way of having a candid discussion.

Despite these complicated dynamics, you need to be able to provide guidelines to your patients and speak truthfully — but empathetically — about health risks related to obesity and sedentary lifestyle, while avoiding a punitive tone. I still cringe when I am reminded of what my friend’s doctor told her: “You need to lose a ton of weight.” This remark was more harmful than helpful. My friend lost a few pounds and then she gained them right back. You will want to create a sense of partnership with your patient, so the two of you can identify tangible and realistic goals together.

Your patient needs to understand that regular, moderate exercise improves physical, mental and emotional health. Studies show that women who are physically active enjoy better health than women who are sedentary.

For many women, a number of factors contribute to negative attitudes toward fitness and exercise. For starters, many women experience their first major failure as girls while participating in organized physical activity such as gym class. Either as a result of PE class or our larger culture, which both tend to place emphasis on athletic skills rather than fitness, the negative attitude begins early and is constantly reinforced. Girls do not understand and often are not taught that “throwing a ball” and being physically fit are not necessarily related. Because of this, many girls begin to feel that they are not good at sports. And this sense of being a “physical loser” can stay with her the rest of her life. So, the seeds of the anti-fitness experience were sowed early in life for many women. The disdain many women feel towards exercise is very old and very persistent.

Most of your patients do know they need to have a healthy lifestyle. How can they not get the message? We are inundated with media stories, advertisements and magazine covers that urge us to exercise or diet. The message is everywhere. To be accepted in our society you must be fit.

For many women, joining a health club is one of the most practical ways to get started exercising. While many will attend the aerobics-type classes, few will venture into the weight room, in part, because they simply do not know what to do and need a teacher.

Let’s return to my friend who has gotten the message that she needs to exercise more and lose weight. She makes her way to her local gym but is overwhelmed and/or grossed out. Though the typical gym has become more women-friendly, in many cases the years of testosterone-laced sweat permeate the walls. The weights clang loudly against the background of loud techno-rock accented with the grunts and groans of 200-plus pound mirror monkeys.

Guess what? These environments are not comfortable to many women but especially those who have never exercised. They are taking what feels like a huge risk. They are not likely to be eager to “perform those undignified positions wearing those unflattering outfits,” according to my friend.

For many women, the health club environment is flat out intimidating and they will never bring themselves to work out in that environment. Emotionally strong, intelligent and successful women, self-confident in every other way, have told me they would never set foot in a health club.

For these women, emotional safety is the key to getting started. There are women-only facilities, and small studios specializing in one-on-one training and in-the-home sessions with personal trainers are becoming more commonplace.

The options are growing and it is important for physicians to become familiar with what resources are available in your community. You need to have a trusted cadre of resources to recommend including studios, personal trainers, nutritionist and fitness clubs. Begin developing relationships with the resources in your community. Ask your women colleagues, staff and patients who they know and trust. Get familiar with the smaller studios where a woman can have complete privacy or personal trainers who will make “house calls.”

Of course many of your patients are not going to be overwhelmed or intimidated by a gym, or much else, for that matter. But they may lack the basic knowledge they need to work out effectively.

Consider strength training — working out with weights, machines, etc. Sound knowledge of what to do with the weights is not innate. Again, men were much more likely to be introduced to weight training as children than women. Resistance exercise can involve an astronomical number of options depending upon: the target muscle, proper movement or form, appropriate amount of weight, type of weight or machine, and body position.

Some of these machines and exercises can and will hurt you if used incorrectly. A weight room is not a place to be without a teacher. If your patient has typical beginner’s gym experience, she will slyly watch the other gym patrons who may or may not know what they are doing.

If she gets lucky and spots someone who does know what they are doing, there is a very low probability that the person she is observing will be doing exercises that will make any sense for her. Chances are her fitness level is different. She may never have lifted a weight in her life. Her body type is different — remember that extra 30 pounds — and her goals are probably different, too. Is she hoping to ward off osteoporosis, tone up or create muscle mass?

Even when your patient is not intimidated by working out at a gym, a personal trainer can be a good idea. A session with a personal fitness trainer or monthly gym membership costs no more than a nice dinner out or a typical trip to the mall. Average fees for certified trainers range from $40 to $100 for a one-hour session. And far from being a luxury, personal fitness training is a symbol of self-respect.

You need to be sure that personal trainers you refer to are certified, insured and are equipped to design programs that address the special biomechanical and physiological, psychological, emotional and social needs of women. For women over 40, a written release for exercise is often required by personal trainers to get started.

While working with a personal trainer may seem extreme, the primary reasons people stop exercising are injuries, soreness and boredom. A competent personal trainer will address these areas to help ensure your patient stays with the program

Another issue women face in trying to justify taking the time and financial resources to exercise or otherwise take care of themselves. Women often put the people who depend on them first in their lives. Their priorities are on kids, spouses, aging parents, friends, neighbors and co-workers. With this line-up of people depending on her, it can be hard to believe that taking time out for herself could be possible.

You need to remind your patient that she will have more energy and feel much better if she makes exercise and healthy eating a routine. You may also want to remind her that it is important that she be healthy if she wants to be here for the people she loves.

Although the benefits of cardio exercise are widely known today, for a lot of women the idea of weight training may be foreign. Be sure your patient understands that in addition to slowing osteoporosis, weight work also builds lean muscle mass. This can be very motivational since the more muscle mass she has, the more calories she burns — even at rest. Also, we lose up to one pound of lean body mass per year starting at about age 20. Maintaining some of that muscle will help burn calories. Your patient may be concerned about adding bulk, so you will need to explain that she will only add bulk if she happens to be taking metabolic steroids!

Some women also find it helpful to exercise with a friend. This is especially true for women who are unable to afford a personal trainer. An exercise partner can offer encouragement and support. It is also very important for you to offer encouragement and lots of positive reinforcement when you see your client adopting a healthier lifestyle. Also, remember that if you cannot be a resource to your patient, she may turn to a quick fix that will jeopardize her health in the long run. With your support and appropriate referrals, your patients can be successful. 

Author: Lynn Adams holds a master’s degree in adult learning and is a certified personal trainer. She specializes in training women who are fitness-phobic at GoddessFit, an all women fitness studio, in Austin, Texas. You can contact Lynn at lynngadams@aol.com.