肥胖的流行需要家庭医师的早期介入


  Oct. 3, 2005 (旧金山)-看到将近三分之一美国成人符合肥胖标准这样的警讯,医师必须跳到第一线试著改变这种情形,并且探索解决这个问题的方法;美国家医学会科学座谈会指出,需要强化医师与病患之间的关系,以告诉病患肥胖所带来对健康的危害,以及更多的关怀来确认与介入孩童时期的肥胖,这个时期的介入可以预防、或至少可以降低对健康长期的影响。
  
  宾州Allentown的小儿科医师Leslie Carroll在孩童肥胖与代谢性症候群的发表会中表示,最重要的是,要记住孩童时期的肥胖是可以逆转的,而且越早介入,改变的机会越大;早期介入尤其重要,因为现在已经知道孩童与青少年时期的代谢症候群,包括高血压、葡萄糖耐受性异常、以及胆固醇过高会同时发生,这些可能会导致早期粥状动脉硬化,且明显地增加发生心血管疾病的风险。
  
  佛州Homestead 的家医科医师Janice Milligan医师表示,肥胖快速地成为公共卫生议题中最重要的一项;她提醒民众肥胖已经成为美国流行病中最引人注意的焦点;肥胖已经变成一种流行病,且在美国已经比C型肝炎或是HIV/AIDS更普遍的疾病;她附带表示,以她的经验而言,这样的诊断是很平常的,而且每个月都会有将近6位病患得到糖尿病。
  
  许多领域的医师都已经学到,「恐吓策略」对成人肥胖病患谈到有关肥胖所带来对健康的影响,包括心血管疾病、特别是糖尿病,一直到那些破坏到他们的健康之前是没效的;对青少年来说,Carroll医师表示,这样的策略更是没效的,因为大部分的孩童不会想到这么久之后的事情,特别是与健康有关的议题。
  
  对于孩童,最好使他或著是她(如果可以的话,与父母合作)认知到因为肥胖所面对的课题,无论是同侪异样的眼光、因为肥胖带来的身体上的不便,并且建立治疗的计画;Carroll医师附带表示,医师与家人通常会鼓励孩童开始健身疗程、或是改变他们有害健康的生活习惯,而这些可能会使孩童重视肥胖所带来的影响;她也指出,与孩童的家人一起努力是很重要的,透过确认肥胖孩童、双亲以及其它的家庭成员对运动、营养、以及生活型态/行为改变已经有充分的认知。
  
  当对年轻病患谈到肥胖时,家庭医师与临床工作者应该参考美国预防医学小组所建议的5个A,分别是评估(assess)、建议(advise)、认同(agree)、协助(assist)、与安排(arrange);这样的步骤包括询问病患有关于肥胖所带来对健康的危害,提供他们有关于改变生活型态更清楚且个人化的建议,并且对共同选择的治疗目标达成协议;接著医师会有较大空间来协助病患成治疗目标,而且他们应该准备好提供更多的协助或支持,透过后续追踪、电话访谈。
  
  认知到肥胖这个议题的重要性,AAFP已经研拟许多标的,并且提供会员相关资源;其中最主要的就是「美国人动起来(AIM)」这个计画,从2003年开始发起,并且已经进入到第3期;在计划进行的头2年,AIM计划将重点放在鼓励家庭医师以及医疗人员们多运动以维持窈窕体态,作为需要接受建议病患的最佳范例。
  
  路易斯安那州Shreveport 家庭医师,同时也是AAFP前任主席Michael Fleming医师表示,整个概念是,在病患心中将健康与家庭医学连结;他一辈子与肥胖对抗,现在作为AIM计画的提倡者,于2003年时承诺每天要走1万步;我们的会员,不论是肥胖或是非肥胖的,已经亲身实践AIM计画,并且将其视为生命中的一部份。
  
  在这个星期的AAFR集会中,AIM计画已经迈入第3期,也就是病患为焦点的阶段,并且散播AIM计画工具,一项包括有关健身与健康饮食的教材、食物与运动追踪表,提供给病患追踪他们的日常饮食、与运动状况,以及一项提供给医师使用的健身处方表。
  
  Fleming医师表示,这项工具没有使用太多的专业术语,而且提供如何介入病患个人健身计画的许多技巧;这项工具目前可以从http://www.aafp.org下载。

Obesity Epidemic Requires Earl

By Bonnie Darves
Medscape Medical News

Oct. 3, 2005 (San Francisco) — In view of the alarming statistic that an estimated one third of U.S. adults meet the criteria for obesity, physicians must jump on the fast-track to try to curtail the epidemic and explore various approaches in working with obese patients. Several speakers here at the American Academy of Family Physicians Scientific Assembly pointed to the need for greater physician-patient partnership to address obesity health risks and a more concerted effort by family physicians to identify and intervene in patient obesity during childhood, when some long-term health effects can be prevented or at least minimized.

"The key thing to remember is that it [childhood obesity] can be reversed, and the earlier the intervention occurs the more potential there is to change" contributing lifestyle and eating factors, said Leslie Carroll, MD, an Allentown, Pennsylvania, pediatrician, during a presentation on obesity and metabolic syndrome in childhood. Early intervention is especially important because it is now known that childhood and adolescent metabolic syndrome, in which hypertension, impaired glucose tolerance, and high cholesterol occur concomitantly, can lead to premature atherosclerosis and significantly increased cardiovascular disease risk early in life.

To drive home the message that obesity is fast moving to the top of the list of public health issues, copresenter Janice Milligan, MD, a Homestead, Florida, family physician, reminded attendees that obesity has taken the top spot on the U.S. epidemic list. "It has become an epidemic, and it is now more prevalent in the United States than either hepatitis C or HIV/AIDS," she said, adding that she herself, in her own practice, now makes the diagnosis routinely and is seeing as many as six patients per month develop diabetes.

As physicians in many specialties have learned, "scare tactics" are ineffective when talking to adult obese patients about obesity's health effects — cardiovascular disease and diabetes in particular —before those effects compromise patients' lives. With adolescents, Dr. Carroll noted, the tactic is even less effective because most children don't think about the long-term effects of any issue, especially health related ones.

It may be more instructive to have the child (in concert with parents, if appropriate) identify concrete issues he or she faces because of obesity, whether it's social ostracization by peers or the sheer physical discomfort of being overweight, and craft a "treatment plan" accordingly. Often, Dr. Carroll noted, physician and family encouragement to start a fitness regimen or change unhealthy behaviors may provide the impetus for a child to address his obesity. She also underlined the importance of involving patients' families, by ensuring that both the obese child and parents and other family members are adequately educated about exercise, nutrition, and lifestyle/behavior change issues.

When counseling young patients about obesity, presenters said, family physicians and clinical staff should adhere to the U.S. Preventive Services Task Force "five A's": assess, advise, agree, assist, and arrange. That approach involves asking patients about health risks, providing clear and personalized advice on behavior change, and agreeing to collaborative selection of treatment goals. Physicians are then better positioned to assist patients in achieving their goals, and they should be prepared to provide ongoing assistance or support through follow-up visits or telephone "checkups" or "check-ins."

In recognition of the growing importance of addressing obesity, the AAFP has developed targeted initiatives and associated resources for members. The primary one is the Americans in Motion (AIM) fitness initiative, conceived in 2003 and now moving into its third phase. In its initial two years, the AIM program focused on encouraging family physicians and their practice staff to increase their own fitness levels to ensure that they exemplified the recommended the lifestyle modifications they might counsel patients to make.

"The whole idea is to — in the patient's mind — connect family medicine with health and wellness," said Michael Fleming, MD. The Shreveport, Louisiana, family physician and past AAFP president, in light of his lifelong struggle with obesity, now serves as the AIM project's designated "poster boy," following his 2003 commitment to walk 10,000 steps a day. "Our members, obese and nonobese alike, have taken this [AIM initiative] on and it's taking on a life of its own," he said.

At the AAFP assembly this week, the AIM project moved into its third, patient-focused phase, with dissemination of an AIM tool kit, a patient-friendly resource that includes education materials on fitness and healthy eating, a food and activity tracker for patient use to track their daily intake and physical activities, and a fitness prescription pad for physician use, among other items.

The tool kit "doesn't use a lot of jargon and provides good tips on how to involve patients in their own personal fitness program," said Dr. Fleming. A downloadable version of the tool kit is now available at http://www.aafp.org.

AAFP 2005 Scientific Assembly: Obesity and Metabolic Syndrome in Children and Adolescents. Presented Sept. 28-29, 2005.

Reviewed by Gary D. Vogin, MD

    
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