Secular trends in the diagnosis and treatment of obesity among US adults in the primary care setting

Excess weight afflicts the majority of the US adult population. Research suggests that the role of primary care physicians in reducing overweight and obesity is essential; moreover, little is known about self-care of obesity. This report assessed the secular trends in the care of overweight and investigated the secular association between obesity with care of overweight in primary care and self-care of overweight. Cross-sectional evaluation of the National Health and Nutrition Examination Survey (NHANES) III (1988-1994) and the Continuous NHANES (1999-2008) was employed; the total sample comprised 31,039 nonpregnant adults aged 20-90 years. The relationship between diagnosed overweight, and directed weight loss with time and obesity was assessed. Despite the combined secular increase in the prevalence of overweight and obesity (BMI >25.0 kg/m(2)) between 1994 and 2008 (56.1-69.1%), there was no secular change in the odds of being diagnosed overweight by a physician when adjusted for covariates; however, overweight and obese individuals were 40 and 42% less likely to self-diagnose as overweight, and 34 and 41% less likely to self-direct weight loss in 2008 compared to 1994, respectively. Physicians were also significantly less likely to direct weight loss for overweight and obese adults with weight-related comorbidities across time (P < 0.05). Thus, the surveillance of secular trends reveals that the likelihood of physician- and self-care of overweight decreased between 1994 and 2008 and further highlights the deficiencies in the management of excess weight.     

Management of alcoholism in the primary care setting.

Primary care physicians can play an important role in managing alcoholic patients. Identifying and treating alcoholism early, before it has interfered with patients'' relationships and work, may increase the likelihood of prolonged recovery. Simple office interventions can help motivate patients to abstain and seek treatment. People who abuse alcohol and are unwilling to abstain can benefit from a recommendation to reduce their intake of alcohol. For alcohol-dependent patients who decide to stop drinking, primary care physicians often can manage withdrawal on an outpatient basis. Selecting an appropriate treatment program for each alcoholic patient is important, and referral to a specialist to assist in matching patients to treatments is often necessary. Primary care physicians also can help prevent relapse. Although disulfiram is of limited value, primary care physicians can support recovery by identifying coexistent psychosocial problems, helping patients to restructure their lives, and ensuring continuity of care.     

Urinary schistosomiasis on Pemba Island: low-cost diagnosis for control in a primary health care setting

In the 1970s and early 1980s indirect diagnosis of urinary schistosomiasis, using urinalysis reagent strips for proteinuria and haematuria, was proposed as a possible alternative to the more accurate but very time-consuming parasitological methods. The recent experience o f the Schistosomiasis Control Programme for Pemba Island, which used a combination of (1) observations o f grossly bloody urine specimens, (2) results from reagent strips for measuring haematuria, and (3) treatment with praziquantel, is the first large-scale example o f a simple, inexpensive and promising alternative for controlling the morbidity caused by this parasite.     

Prevalence of obese patients in a primary care setting

Objective: Previous research has addressed the relationship between BMI and chronic disease in primary care; however, little has been done with regard to the association between obesity and depression in primary care. The purpose of this paper is to assess the relationship between obesity and chronic conditions including depression. Research Methods and Procedures : Data from primary care patients seen at a university‐based family medicine clinic in the southeastern United States were extracted for the time between January 1, 1999 and January 1, 2002. Data extracted included most recent height and weight, age, ethnicity, pregnancy status, number of office visits, blood pressure, cholesterol, hemoglobin A_1C, current diagnoses, and medications. Results : A total of 8197 patients were included in the analysis. Sixty‐nine percent of patients seen in a 3‐year period were either overweight or obese. Comparing blood pressure, cholesterol, diagnoses, and medications between BMI groups found differences in virtually all categories. Diagnoses of high cholesterol, hypertension, diabetes, and depression significantly increased for obese patients. Discussion : Obese patients are over‐represented in primary care, and this over‐representation of obesity correlates with several diagnoses, including depression. Depression is a chronic disease that may interfere with health‐related behaviors and must be addressed within the health care system.     

Screening and diagnosis of alcoholism in the primary care setting.

As many as 20% of patients seeing their primary physicians may suffer from alcohol abuse and dependence. Often the problem goes unrecognized. In this article I summarize what is known regarding the natural history, risk factors, and available screening techniques for alcoholism. Ultimately, a diagnosis of alcoholism is based on a patient''s history, and there are various approaches to obtaining a thorough alcohol history and overcoming patient denial regarding an alcohol problem. Primary physicians have an important role in educating patients about alcoholism.     

Cystic fibrosis carrier population screening in the primary care setting.

To determine the receptivity of prenatal care providers and their patients to carrier testing for cystic fibrosis (CF), we offered free carrier screening, followed by genetic counseling of carriers, to all prenatal care providers in Rochester, NY, for all their female patients of reproductive age, pregnant or not. Of 124 prenatal care providers, only 37 elected to participate, but many of these offered screening only to pregnant women. The acceptance rate among pregnant women was approximately 57%. The most common reasons for accepting screening were to obtain reassurance (50.7%) and to avoid having a child with CF (27.8 %). The most common reasons for declining screening were not intending to terminate a pregnancy for CF (32.4%) and believing that the chance of having a CF child was very low (32.2%). Compared with decliners, acceptors were more likely to have no children, regarded having a child with CF as more serious, believed themselves more susceptible to having such a child, knew more about CF, would be more likely to terminate a pregnancy if the fetus were shown to have CF, and more strongly supported offering CF screening to women of reproductive age. Of 4,879 women on whom results were obtained, 124 were found to be carriers. Of these 124 carriers, the partners of 106 were tested. Of the five at-risk couples, four requested prenatal diagnosis and one requested neonatal diagnosis. No woman found to be a carrier whose partner tested negative requested prenatal diagnosis. Except for the imperfect knowledge of those testing negative, none of the adverse outcomes predicted for CF carrier testing in the general population were observed in this study.     

The presence of HIV infection in a hospital-based primary care setting

Background: The incidence of HIV infection in the general population continues to grow as a cure is yet to be found. Fortunately, great strides have been made in treating this multifactorial disease so patients are living longer and more productive lives. As a result, there is a growing demand from all health care disciplines, including optometry, to provide care for patients with HIV infection. Methods: From June 1, 1994 through May 30, 1995, HIV seropositive patients presenting to the primary care optometry clinic at the Bascom Palmer Eye Institute were identified from the total clinic population. All patients presented to the clinic as part of a routine eye exam or were referred by a primary physician. All abnormal findings were recorded in a log in addition to the CD4⁺ T-cell count. Results: One hundred and fifty HIV seropositive patients were identified from the clinic population. Fifty percent were ocularly abnormal including 31 patients (20.7%) with HIV microangiopathy, and nine patients (6%) with CMV retinitis. One hundred and eighteen patients (78.7%) knew their CD4 count. There was a correlation between HIV-related ocular findings and low CD4 counts. Similarly 65.6% of the patients who did not know or did not share their CD4 counts had abnormalities in their eye exam with 52.4% being HIV related. Conclusion: Optometrists play an important part of the health care team since patients with HIV infection present to primary care optometrists for comprehensive eye care as demonstrated in this study. The optometrist must be aware of the status of their CD4 count as this helps determine the risk for having HIV-related problems. Many patients will be able to provide this information as shown. Caution must be displayed with patients who do not know their CD4 count as this may be a poor prognostic sign. Finally, optometrists must educate patients about the risk for developing ocular complications from HIV as part of their eye care as both HIV microangiography and CMV retinitis were the most common AIDS-related ocular findings.     

Genetic testing and primary care: a new ethic for a new setting

For several decades, clinical geneticists have espoused two key ethical principles, nondirectiveness and confidentiality. These principles made a great deal of sense in the highly personal and controversial setting of reproductive genetics. Now that clinical genetics has entered the primary care setting, clinicians are rethinking the strength of their commitment to these traditional norms and they are revamping their ethical priorities. Patients increasingly need advice about whether they should take genetic tests and whether and how they should respond to the test results. Patients also need to know about how this information will impact family members and whether other members of their family should be tested. Clinical geneticists may even consider breaking individual confidentiality in order to prevent harms to family members. Although clinical geneticists do not need to abandon nondirectiveness and confidentiality in this new setting, they may not strictly adhere to these principles in some circumstances in order to benefit patients and their families.     

Patients' perceptions of need for primary health care services: useful for priority setting?

OBJECTIVES--To assess the feasibility of using patients'' perceptions of need for primary health care services to develop priorities. DESIGN--A postal survey of a random sample of 3478 patients registered with five general practices. SETTING--Lothian, Scotland. MAIN OUTCOME MEASURES--Comparison of rankings of 36 different kinds of help or advice according to (a) popularity in the sample size as a whole and in healthy and unhealthy subgroups and (b) health status (severity of need) of potential service users. RESULTS--Popularity rankings differed between the healthy and unhealthy subgroups and the whole sample. Popularity rankings were almost the inverse of rankings based on health status. The analysis identified two areas of substantial need both in terms of popularity and severity: pain management and advice about welfare benefits. CONCLUSIONS--Methodological efforts to ensure equal participation in the processes of assessing health needs and of priority setting do not in themselves promote equity. To promote equity some opinions may need to be given greater weight.     

Genetic testing and primary care: a new ethic for a new setting

For several decades, clinical geneticists have espoused two key ethical principles, nondirectiveness and confidentiality. These principles made a great deal of sense in the highly personal and controversial setting of reproductive genetics. Now that clinical genetics has entered the primary care setting, clinicians are rethinking the strength of their commitment to these traditional norms and they are revamping their ethical priorities. Patients increasingly need advice about whether they should take genetic tests and whether and how they should respond to the test results. Patients also need to know about how this information will impact family members and whether other members of their family should be tested. Clinical geneticists may even consider breaking individual confidentiality in order to prevent harms to family members. Although clinical geneticists do not need to abandon nondirectiveness and confidentiality in this new setting, they may not strictly adhere to these principles in some circumstances in order to benefit patients and their families.     

Ghrelin and appetite control in humans--potential application in the treatment of obesity

Ghrelin is a peptide hormone secreted into circulation from the stomach. It has been postulated to act as a signal of hunger. Ghrelin administration acutely increases energy intake in lean and obese humans and chronically induces weight gain and adiposity in rodents. Circulating ghrelin levels are elevated by fasting and suppressed following a meal. Inhibiting ghrelin signaling therefore appears an attractive target for anti-obesity therapies. A number of different approaches to inhibiting the ghrelin system to treat obesity have been explored. Despite this, over a decade after its discovery, no ghrelin based anti-obesity therapies are close to reaching the market. This article discusses the role of ghrelin in appetite control in humans, examines different approaches to inhibiting the ghrelin system and assesses their potential as anti-obesity therapies.     

Algorithms for the diagnosis and treatment of restless legs syndrome in primary care

Background

Restless legs syndrome (RLS) is a neurological disorder with a lifetime prevalence of 3-10%. in European studies. However, the diagnosis of RLS in primary care remains low and mistreatment is common.

Methods

The current article reports on the considerations of RLS diagnosis and management that were made during a European Restless Legs Syndrome Study Group (EURLSSG)-sponsored task force consisting of experts and primary care practioners. The task force sought to develop a better understanding of barriers to diagnosis in primary care practice and overcome these barriers with diagnostic and treatment algorithms.

Results

The barriers to diagnosis identified by the task force include the presentation of symptoms, the language used to describe them, the actual term "restless legs syndrome" and difficulties in the differential diagnosis of RLS.

Conclusion

The EURLSSG task force reached a consensus and agreed on the diagnostic and treatment algorithms published here.