Report 8 of the Council on Scientific Affairs (A-04)
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AMA Actions on Obesity

Over the past year, the AMA has worked with the Council on Scientific Affairs (CSA), other units within the association, national organizations, and groups of experts to address the measures called for in Resolution 405 (A-03). Growing scientific information on the clinical epidemiology of obesity and its impact on health and medical care requires that medicine vigorously identify strategies for prevention and intervention. Although consensus on best strategies is still evolving, the AMA has begun to act. This informational report updates the House of Delegates on actions the AMA has undertaken to address the obesity epidemic and the recommendations of Resolution 405 (A-03).

Background

CSA Report 6 (A-99), Obesity as a Major Public Health Problem, reviewed the epidemiology of obesity and the nature of the problems it causes. The report included the following recommendations:

• The AMA urges physicians as well as managed care organizations and other third-party payors to recognize obesity as a complex disorder involving appetite regulation and energy metabolism that is associated with a variety of comorbid conditions.
• The AMA will work with appropriate federal agencies, medical specialty societies, and public health organizations to educate physicians about the prevention and management of overweight and obesity in children and adults, including education in basic principles and practices of physical activity and nutrition counseling; such training should be included in undergraduate and graduate medical education and through accredited continuing medical education (CME) programs.
• The AMA urges federal support of research to determine (a) the causes and mechanisms of overweight and obesity, including biological, social, and epidemiological influences on weight gain, weight loss, and weight maintenance; (b) the long-term safety and efficacy of voluntary weight maintenance and weight loss practices and therapies, including surgery; (c) effective interventions to prevent obesity in children and adults; and (d) the effectiveness of weight loss counseling by physicians.
• The AMA encourages national efforts to educate the public about the health risks of being overweight and obese and provide information about how to achieve and maintain a preferred healthy weight.
• The AMA urges physicians to assess their patients for overweight and obesity during routine medical examinations and discuss with at-risk patients the health consequences of further weight gain; if treatment is indicated, physicians should encourage and facilitate weight maintenance or reduction efforts in their patients or refer them to a physician with special interest and expertise in the clinical management of obesity.
• The AMA urges all physicians and patients to maintain a desired weight and prevent inappropriate weight gain.
• The AMA encourages physicians to become knowledgeable of community resources and referral services that can assist with the management of overweight and obese patients.
• The AMA urges the appropriate federal agencies to work with organized medicine and the health insurance industry to develop coding and payment mechanisms for the evaluation and management of obesity.

Since CSA Report 6 (A-99) was written, greater national attention has been directed at obesity as an epidemic of major proportions. Data from national studies show that the percentage of the U.S. adult population who are obese (body mass index [BMI] >29.9) has risen from approximately 13.5% in the early 1960s to approximately 30% in the late 1990s.¹ During this same period, the number of people with extreme obesity (BMI >39.9) has increased from 2.9% to 4.7%. An estimated 131 million American adults are overweight or obese. Trends for children and youth parallel the epidemiology for adults--approximately 30% of school-aged children are overweight or at risk for overweight and approximately 15% are obese.²

Although obesity is epidemic in society, certain population groups have experienced greater weight gains than others. Thus, rates of overweight and obesity are greater among women, and among minority populations.¹ However, the relationship among race/ethnicity, socioeconomic status (SES), and gender is complex. Racial/ethnic group differences in obesity are not found for adult men. Overweight and obesity are greatest among non-Hispanic black women; more than half of this population aged 40 years or older are obese, more than 15% have extreme obesity (class III or morbid obesity), and more than 80% are overweight.¹ Hispanic women are more likely than non-Hispanic white women but less likely than non-Hispanic black women to be overweight and obese. Data from a large national study further describe group differences in weight status among adolescents.³ Although racial/ethnic groups differed in rates of being overweight, a clear inverse relationship between SES and weight was found only for white females. Thus, non-Hispanic black and Asian females from lower SES family backgrounds were as likely to be overweight as minority females from higher SES families.

New research results also clearly show the relationship between weight and morbidity. For example, longitudinal data from the 18-year Nurses' Health Study and the 10-year Health Professionals Follow-up Study demonstrate large increases in relative risk for type 2 diabetes, cholelithiasis, hypertension, and coronary heart disease that occur among adults with increasing BMI.⁴ Excessive weight also is associated with increases in inflammatory markers such as C-reactive protein and fibrinogen in adults and children, osteoarthritis, and some types of cancer.^5-9 Finally, obese children have a greater risk for emotional problems and reduced quality of life.^10-12

Recent research has begun to demonstrate the economic burden of obesity on health care. Sturm,¹³ using 1997-1998 data from approximately 10,000 household respondents, found that obesity was more strongly associated with chronic medical conditions, reduced health-related quality of life, and increased health care and medication spending than either smoking or problem drinking. Colditz¹⁴ has estimated the direct cost of obesity in the United States at $70 billion, while Wang and Dietz¹⁵ found that obesity-associated annual hospital costs increased more than threefold, from $35 million during 1979-1981 to $127 million during 1997-1999.

The importance of obesity as a public health problem is further reinforced by the results of a recent study by the Centers for Disease Control and Prevention. Linking risk behaviors and mortality, researchers found that tobacco use is the leading cause of death, accounting for 18.1% of total U.S. deaths for 2000, while poor diet and physical inactivity accounted for 16.6% of deaths.¹⁶ Overall, risk behaviors accounted for 48.2% percent of deaths. Considering the rising rate of obesity, the researchers conclude that poor diet and physical inactivity may soon overtake tobacco use as the leading cause of death.

Treatment options and recommendations for managing obesity, including bariatric surgery, pharmacotherapy, and counseling, have expanded since 1999. In 2003, the U.S. Preventive Services Task Force concluded that data were sufficient to recommend that physicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults.¹⁷ Other sets of clinical recommendations directed at adult and childhood obesity have also been developed recently by national organizations and experts.^8,18-21 In a recent systematic review of the literature, researchers concluded that the lack of quality studies limits recommendations for improving health professionals’ management of obesity.²² However, reminder systems, brief training interventions, shared care, inpatient care, and dietitian-led treatments provided promise and warrant further study.

Political advocacy for government action is also becoming prominent as a strategy to prevent obesity. Thus, actions such as eliminating soda vending machines in schools, expanding food labeling, requiring healthier school lunch programs, increasing physical education in schools, and requiring restaurants to list nutrition information are being debated at the local, state, and federal levels.^23-24 The results of one national poll indicated that most adults are ambivalent about the role of government in fighting adult obesity, but relatively strongly support such involvement in childhood obesity (eg, healthier school lunch programs, more school physical activity, health classes on exercise and diet, and prohibiting the sale of unhealthy foods in school vending machines).²⁴ In an interesting analysis of previous major national public health debates, Kersh and Morone²⁵ identified 7 steps that trigger government action. They propose that many of these steps are occurring in the discussions surrounding obesity. These steps are: massive social disapproval; scientific discoveries that lead to medical warnings; emergence of self-help movements; a focus on demonizing users; a focus on demonizing an industry; mass, organized activist movement; and interest-group action.

Recent Actions of the AMA

In response to direction of the House of Delegates, the AMA has begun developing a program to address obesity among both adults and children. Although this program is still emerging, the following are activities to date.

AMA Roadmap for Clinical Practice--Assessment and Evaluation of Adult Obesity: A Primer for Physicians.In December 2003 the AMA released the second volume in the "Roadmaps for Clinical Practice" series. The purpose of the series is to help physicians practice disease prevention and health promotion through synthesizing medical and public health science into clinical application.

The primer, authored by Robert Kushner, MD, is a 10-booklet set that targets physicians in primary care practices. Each volume is case-based and addresses critical skill sets essential for evaluating obesity and establishing an effective management plan. Specialists from various medical and health disciplines, along with representatives of Federation organizations, participated in the development and review of the content and design. The product, developed in part with funding from The Robert Wood Johnson Foundation, includes a CD-ROM, and offers 4.5 hours of CME. Questionnaires, charts, and other materials are included to aid in patient management. Copies of the primer were distributed to physician organizations and educational institutions during the first quarter of 2004. The primer is available at no cost through the AMA product fulfillment center: 1/800-262-3211 (product code NC426203). It also can be downloaded from the Internet (www.ama-assn.org/go/roadmaps).

AMA Working Group on Childhood Obesity: In November 2003, the AMA convened representatives of 30 national medical, public health, youth-serving, and community organizations to identify strategies for working through medical practices to address childhood obesity. Keynote presentations provided an overview of the obesity problem among children, insight into family community factors that affect childhood obesity, and a discussion of obesity within minority communities. Nancy Krebs, MD (American Academy of Pediatrics) and Michael Gonzales-Compoy, MD, PhD (AMA Minority Affairs Consortium) co-chaired the meeting. Recommendations from the meeting included:

• Develop and promote a unified and consistent communication message regarding overweight and obesity that bridges both physicians and nonphysicians working with children and their families.
• Increase physician awareness of the value and use of the BMI.
• Urge physicians to intervene early – children and youth might not just "grow out of" being obese.
• Educate physicians on what to say to patients and parents (eg, excess weight is a danger to your health; what do you think about exercise?)
• Involve parents in management plans.
• Counsel parents to limit the amount of TV viewed by their children.
• Counsel children and parents that any increase in movement can be helpful.

Adolescent Obesity, Nutrition, and Physical Activity: This monograph on adolescent obesity, released in November 2003, contains the proceedings of two meetings of the AMA Educational Forum on Adolescent Health. The Forum, and its associated meeting of the AMA National Coalition on Adolescent Health, consists of representatives from 35 national organizations, 20 of which are in the Federation. The semi-annual meetings are sponsored, in part, through a cooperative agreement with the Maternal and Child Health Bureau's Office on Adolescent Health. The monograph features presentations by eight speakers, answers to audience questions, an extensive bibliography, resources, and areas for future research. It is available in hard copy and can be obtained by submitting an email request to staff in the Unit on Medicine and Public Health (missy_fleming@ama-assn.org).

Educational Session at the 2003 AMA Interim Meeting: The CSA sponsored an educational session on adult obesity at the 2003 AMA Interim Meeting. Robert Kushner, MD, from Northwestern University School of Medicine presented an overview of the obesity epidemic and announced the release of the obesity primer. Wayne Burton, MD, Corporate Medical Director of Bank One, discussed the economic impact of obesity and Gary Bryant, MD, described the experience of the Wisconsin Medical Society's pedometer give-away program.

AMA Publications: In 2003, AMNews published approximately 30 major articles on overweight and obesity, while JAMA published more than 40 scientific studies and editorials on this subject.

Conclusion

Recognizing the magnitude of obesity and its impact on health and health care, the AMA will proceed with the following activities:

1. In association with the AMA Working Group on Childhood Obesity, develop and disseminate a set of key communication points cutting across health professionals and community groups. The group thought it important that medical and nonmedical people working with children, youth, and families promote common social marketing messages that encourage both prevention and early identification and management.
2. Contingent on identification of extramural funding, develop a Speaker’s Kit and physician training materials based on the adult obesity primer.
3. Assess the value of convening a National Summit on Obesity to further the dialogue on classifying obesity as a disease. This meeting, to be held no sooner than Fall 2004, would include national organizations that have a vested interest in obesity.
4. Pursue, in collaboration with Federation organizations, legislative and regulatory strategies for preventing obesity, when appropriate.
5. Request that the AMA Physician Consortium for Performance Improvement consider options for developing a measurement set for obesity.
6. Work with the Centers for Disease Control and Prevention and other national groups to update clinical pathways for identification and management of children with obesity.
7. Develop and promote through the World Wide Web an inventory of actions and programs on obesity that are sponsored by Federation organizations.

RECOMMENDATIONS

Because this is an informational report, there are no recommendations.

References

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Resolution 405, introduced by the American Society of Bariatric Physicians and adopted at the 2003 Annual Meeting, called on the American Medical Association (AMA) to: