It Is Not A Small World (or US) After All

I found this article in Synapse, the USCSF, the student paper. I'm not one to talk being 15 lbs over my optimum weight, but if you go to the entertainment parks and anywhere large amounts of people congregate, you will actually see that there is a big problem in the US with obesity.

A New Motto for Weight Loss: Keep Disneyland Open By Alison Silvis

Look to Disneyland for the latest symptom of the obesity epidemic. The park’s “It’s a Small World” ride is simply too small to accommodate the extra 24 pounds the average American has packed on since 1960. Stalls and stops are so common that extra platforms have been built at problem hotspots along the ride. Now, the ride will be closing for ten months beginning in January for refurbishment with larger flume cars and deeper waterways.

As future health-care professionals, this is one more sign of the environment in which we will be practicing. Patients are getting heavier, more sedentary and in greater need of preventative care and support for behavior change. Evidence-based medicine should be the gold standard for such care. But we still cannot answer the simple question: how much weight gain is bad? And how much is good?

The November 7 issue of JAMA contains an article that adds to our understanding of the already-complex relationship between weight and health, but raises many questions about the supposed protective effect of being overweight. Knowing how to interpret articles and how to individualize research findings to a patient is our responsibility. But this is only one component of employing evidence-based medicine. It also means making sure patients understand the information, and then following up to see how they apply that information to their lives. This is easier said than done, of course, but that does not justify giving up.

The same issue of JAMA offered some hope in how to support long-term weight management behaviors, in the discussion of one physician’s efforts to manage the care of an obese patient with several health complications (“Clinical Crossroads: A 63-Year-Old Man with Multiple Cardiovascular Risk Factors and Poor Adherence to Treatment Plans”). The author, Dr. Bodenheimer, emphasized the importance of clinical care teams that work to merge a patient’s goals with clinicians’ goals. A patient’s participation in her care may be the single most important factor in adherence to medication, and presumably plays a fundamental role in determining adherence to behavior change.

In this sense, a clinician’s role may evolve into one of “self-management support,” providing information and resources to initiate and maintain healthy behavior outside of clinic visits. One promising model of this type of chronic care is at Health Partners Medical Group in Minnesota. There, patients receive previsit, visit, postvisit, and between-visit care from a variety of health professionals. Clearly, collaboration within the health professions and between clinicians and patients is essential to this model. Whether or not it improves patient outcomes is yet to be determined, but the current system is clearly failing.

We cannot afford to ignore the painful reality of the obesity epidemic. In Disneyland, when heavy patrons are disgruntled at being asked to step off the ride, they are offered a food voucher. In the world of evidence-based medicine, we need to challenge patients to confront the reality of their daily lifestyle choices, and then work with them to modify those that are unhealthy. We owe it to them.