The Impact of Obesity on Primary Care Visits

Objective: To investigate the influence of patient obesity on primary care physician practice style. Research Methods and Procedures: This was a randomized, prospective study of 509 patients assigned for care by 105 primary care resident physicians. Patient data collected included sociodemographic information, self‐reported health status (Medical Outcomes Study Short Form‐36), evaluation for depression (Beck Depression Index), and satisfaction. Height and weight were measured to calculate the BMI. Videotapes of the visits were analyzed using the Davis Observation Code (DOC). Results: Regression equations were estimated relating obesity to visit length, each of the 20 individual DOC codes, and the six DOC Physician Practice Behavior Clusters, controlling for patient health status and sociodemographics. Obesity was not significantly associated with the length of the visit, but influenced what happened during the visit. Physicians spent less time educating obese patients about their health (p = 0.0062) and more time discussing exercise (p = 0.0075). Obesity was not related to discussions regarding nutrition. Physicians spent a greater portion of the visit on technical tasks when the patient was obese (p = 0.0528). Mean pre‐visit general satisfaction for obese patients was significantly lower than for non‐obese patients (p = 0.0069); however, there was no difference in post‐visit patient satisfaction. Discussion: Patient obesity impacts the medical visit. Further research can promote a greater understanding of the relationships between obese patients and their physicians.     

Smoking: Its Impact on Urologic Health

Tobacco use remains the single largest preventable cause of disease and premature death in the United States, and smoking is a leading cause of cancer and death from cancer. There is also evidence that smoking is associated with several urologic diseases. Urologists have a unique opportunity to help our patients lead healthy lifestyles, which includes ending their dependence on nicotine and tobacco. This article points out the various urologic conditions associated with smoking and tobacco use with the intention of providing physicians and patients with knowledge and education regarding this connection.Key words: Bladder cancer, Prostate cancer, Kidney cancer, Erectile dysfunction, Interstitial cystitisSmoking remains one of the greatest health threats to our nation, and the death rate among current smokers is two to three times that of nonsmokers.¹ There is also evidence that smoking is associated with several urologic diseases. If we are to be effective healthcare providers, urologists must make a concerted effort to make our patients aware of the connections between tobacco and common urologic diseases. Also, urologists are in the unique position to motivate patients to stop smoking and to enter smoking cessation programs. This article points out the various urologic conditions associated with smoking and tobacco use with the intention of providing physicians and patients with knowledge and education regarding this connection.     

The Obesity Epidemic and Future Emergency Responders

Emergency responders should be fit to safely perform strenuous duties. In particular, young recruits are expected to be at or near peak career fitness. We studied the prevalence and health associations of excess weight among 370 consecutive emergency responder candidates for fire and ambulance services in Massachusetts. The mean age and BMI of the recruits were 26.3 (3.8) years and 28.5 (4.9) kg/m², respectively. Seventy‐seven percent had BMI ≥25 kg/m², and 33% were obese (BMI ≥30 kg/m²). After multivariate adjustment, both higher BMI categories and unit increases in BMI were significantly associated with higher blood pressures, worse metabolic profiles, and lower exercise tolerance. Excess weight is highly prevalent and associated with elevated cardiovascular risk among future emergency responders. These findings in a population expected to perform demanding duties supporting public safety merit prompt public health intervention.     

The Canadian Obesity Epidemic: An Historical Perspective

Objective: To examine temporal trends in stature, body mass, body mass index (BMI), and the prevalence of overweight and obesity in Canada. Research Methods and Procedures: Data for adults 20 to 64 years of age were compared across eight Canadian surveys conducted between 1953 and 1998. Temporal trends in stature and body mass were examined using regression, and changes in weight‐for‐height were expressed as changes from 1953. BMI data were available from 1970 to 1972 to examine changes in overweight and obesity. Qualitative changes in the BMI distribution were examined using Tukey mean‐difference plots. Results: Significant temporal trends in stature and body mass have occurred since 1953 in Canada. Median stature increased 1.4 cm/decade in men and 1.1 cm/decade in women, whereas median body mass increased 1.9 kg/decade in men and 0.8 kg/decade in women. Increases in the 75th percentile of body mass were larger than the median. The average weight‐for‐height increased 5.1% in men and 4.9% in women from 1953. Furthermore, the prevalences of overweight and obesity have increased from 40.0% and 9.7% in 1970–1972 to 50.7% and 14.9% in 1998, respectively. The entire BMI distribution has shifted to the right since 1970–1972 and has become more skewed to the right for men than for women. Discussion: There have been significant increases in stature and body mass in Canada over the last 45 years. Body mass has increased more than stature, particularly in the upper percentiles, which has resulted in the currently observed high prevalences of overweight and obesity.     

Primary Care Physicians’ Attitudes about Obesity and Its Treatment

Objective: This study was designed to assess physicians’ attitudes toward obese patients and the causes and treatment of obesity. Research Methods and Procedures: A questionnaire assessed attitudes in 2 geographically representative national random samples of 5000 primary care physicians. In one sample (N = 2500), obesity was defined as a BMI of 30 to 40 kg/m², and in the other (N = 2500), obesity was defined as a BMI > 40. Results: Six hundred twenty physicians responded. They rated physical inactivity as significantly more important than any other cause of obesity (p < 0.0009). Two other behavioral factors—overeating and a high‐fat diet—received the next highest mean ratings. More than 50% of physicians viewed obese patients as awkward, unattractive, ugly, and noncompliant. The treatment of obesity was rated as significantly less effective (p < 0.001) than therapies for 9 of 10 chronic conditions. Most respondents (75%), however, agreed with the consensus recommendations that a 10% reduction in weight is sufficient to improve obesity‐related health complications and viewed a 14% weight loss (i.e., 78 ± 5 kg from an initial weight of 91 kg) as an acceptable treatment outcome. More than one‐half (54%) would spend more time working on weight management issues if their time was reimbursed appropriately. Discussion: Primary care physicians view obesity as largely a behavioral problem and share our broader society's negative stereotypes about the personal attributes of obese persons. Practitioners are realistic about treatment outcomes but view obesity treatment as less effective than treatment of most other chronic conditions.     

The Obesity Epidemic: Metabolic Imprinting on Genetically Susceptible Neural Circuits

The apparent obesity epidemic in the industrialized world is not explained completely by increased food intake or decreased energy expenditure. Once obesity develops in genetically predisposed individuals, their obese body weight is avidly defended against chronic caloric restriction. In animals genetically predisposed toward obesity, there are multiple abnormalities of neural function that prime them to become obese when dietary caloric density and quantity are raised. Once obesity is fully developed, these abnormalities largely disappear. This suggests that obesity might be the normal state for such individuals. Formation of new neural circuits involved in energy homeostasis might underlie the near permanence of the obese body weight. Such neural plasticity can occur during both nervous system development and in adult life. Maternal diabetes, obesity, and undernutrition have all been associated with obesity in the offspring of such mothers, especially in genetically predisposed individuals. Altered brain neural circuitry and function often accompanies such obesity. This enhanced obesity may then be passed on to subsequent generations in a feed‐forward, upward spiral of increasing body weight across generations. Such findings suggest a form of “metabolic imprinting” upon genetically predisposed neural circuits involved in energy homeostasis. Centrally acting drugs used for obesity treatment lower the defended body weight and alter the function of neural pathways involved in energy homeostasis. But they generally have no permanent effect on body weight or neural function. Thus, early identification of obesity‐prone mothers, infants, and adults and treatment of early obesity may be the only way to prevent the formation of permanent neural connections that promote and perpetuate obesity in genetically predisposed individuals.     

Complementary Hypotheses on Contributors to the Obesity Epidemic

Increased rates of obesity have occurred within virtually every race, age, sex, ethnicity, and economic group. Despite substantial punditry on the issue, the exact reasons are incompletely known. The two most common factors cited as contributing to the obesity epidemic, and those whose causal influence on increasing obesity levels in the population are often presumed unequivocally, are food marketing practices and institutionally driven reductions in physical activity. These have been called “the big two.” This Perspective builds on previous writings in this area to introduce additional factors that may contribute to the obesity epidemic. It is emphasized that there may be other factors working in combination with the big two, influencing body fatness through effects on energy intake, energy expenditure, and/or nutrient partitioning.     

3D Printing and Its Urologic Applications

3D printing is the development of 3D objects via an additive process in which successive layers of material are applied under computer control. This article discusses 3D printing, with an emphasis on its historical context and its potential use in the field of urology.Key words: Medical applications of 3D printing, Urologic applications of 3D printing, BiofabricationA 3D printer is unlike the printers most commonly used in a urology office. 3D printing is also known as desktop fabrication or additive manufacturing. It is a prototyping process whereby a real object is created from a 3D computer-created design. The digital 3D model file is sent to the 3D printer, which prints the design one layer at a time, forming a 3D object.¹The smallest 3D printer weighs 1.5 kg and costs approximately ≥1600. The biggest drawback for the individual small practice user is the relatively high cost of the printer.² In addition to the cost of the hardware, the professional 3D software and 3D model design are likewise expensive³ and is beyond the budget of most urologic practices. A list of commercial 3D printers currently available is shown in

Age at Puberty and the Emerging Obesity Epidemic

Background

Recent studies have shown that puberty starts at younger ages than previously. It has been hypothesized that the increasing prevalence of childhood obesity is contributing to this trend. The purpose of this study was to analyze the association between prepubertal body mass index (BMI) and pubertal timing, as assessed by age at onset of pubertal growth spurt (OGS) and at peak height velocity (PHV), and the secular trend of pubertal timing given the prepubertal BMI.

Methodology/Principal Findings

Annual measurements of height and weight were available in all children born from 1930 to 1969 who attended primary school in the Copenhagen municipality; 156,835 children fulfilled the criteria for determining age at OGS and PHV. The effect of prepubertal BMI at age seven on these markers of pubertal development within and between birth cohorts was analyzed. BMI at seven years was significantly inversely associated with age at OGS and PHV. Dividing the children into five levels of prepubertal BMI, we found a similar secular trend toward earlier maturation in all BMI groups.

Conclusion/Significance

The heavier both boys and girls were at age seven, the earlier they entered puberty. Irrespective of level of BMI at age seven, there was a downward trend in the age at attaining puberty in both boys and girls, which suggests that the obesity epidemic is not solely responsible for the trend.     

The Potential Role of Protein Leverage in the US Obesity Epidemic

The protein leverage model of obesity posits that decreasing the protein fraction of the diet leads to compensatory increases in total energy intake in an attempt to maintain a target amount of absolute protein consumed. The resulting increased energy intake thereby causes weight gain. According to food balance sheets published by the Food and Agriculture Organization of the United Nations, while the absolute protein content of the US food supply has increased since the early 1970s, the fraction of available calories from protein has decreased by ~1% because of greater increases in available carbohydrate and fat. Counterintuitively, even such a small decrease in the protein fraction of the food supply has the potential to result in relatively large increases in energy intake according to the protein leverage model. Therefore, while the protein leverage effect is unlikely to fully explain the obesity epidemic, its potential contribution should not be ignored.     

Exploiting Social Networks to Mitigate the Obesity Epidemic

Despite significant efforts, obesity continues to be a major public health problem, and there are surprisingly few effective strategies for its prevention and treatment. We now realize that healthy diet and activity patterns are difficult to maintain in the current physical environment. Recently, it was suggested that the social environment also contributes to obesity. Therefore, using network‐based interaction models, we simulate how obesity spreads along social networks and predict the effectiveness of large‐scale weight management interventions. For a wide variety of conditions and networks, we show that individuals with similar BMIs will cluster together into groups, and if left unchecked, current social forces will drive these groups toward increasing obesity. Our simulations show that many traditional weight management interventions fail because they target overweight and obese individuals without consideration of their surrounding cluster and wider social network. The popular strategy for dieting with friends is shown to be an ineffective long‐term weight loss strategy, whereas dieting with friends of friends can be somewhat more effective by forcing a shift in cluster boundaries. Fortunately, our simulations also show that interventions targeting well‐connected and/or normal weight individuals at the edges of a cluster may quickly halt the spread of obesity. Furthermore, by changing social forces and altering the behavior of a small but random assortment of both obese and normal weight individuals, highly effective network‐driven strategies can reverse current trends and return large segments of the population to a healthier weight.     

The Impact of Obesity and Arthritis on Active Life Expectancy in Older Americans

This article examines the relationship of obesity and arthritis to length of life and length of disabled life in older American men and women. Secondary data analysis is conducted on three waves of the Asset and Health Dynamics Among the Oldest Old (AHEAD) survey (n = 7,381). Using integrated Markov chains, total, active, and disabled life expectancy in Americans aged ≥70 is estimated, with and without obesity and arthritis. Results indicate that neither obesity nor arthritis is related to the length of life for older men and women, alone or in combination. However, both conditions are significantly individually associated with increased length of disabled life in older men (1.4 years attributable to obesity; 1.2 years to arthritis at age 70; P < 0.05) and women (1.7 years attributable to obesity; 2.1 years to arthritis at age 70; P < 0.05). In addition, the combination of the two is significantly related to decreased active life, with nearly 50 and 60% of remaining life for 70‐year‐old men and women lived with disability, respectively (P < 0.05). Coupled with the fact that both obesity and arthritis are growing in prevalence, these findings represent one of the few clearly negative health trends in older adults today. These results should provide incentives for health‐care professionals to make concerted efforts to address both conditions in clinical settings.     

Management of Obesity in Primary Care

SIMKIN-SILVERMAN, LAUREY R, RENA R WING. Management of obesity in primary care. Obesity is one of the most common presenting chronic medical conditions in primary care, yet it is not adequately treated. Physicians are often reluctant to counsel patients because of their limited training in treating chronic weight problems and negative attitudes toward obese patients. This study evaluated the feasibility of training physicians to provide weight control counseling to their patients. Eleven physicians were randomly assigned to either an obesity-counseling skills training group or to a control group. Physicians in the counseling skills group received training in behavioral and motivational weight control techniques using a five-step patient-centered model; they were also given patient materials for use in their practice. To evaluate pretraining to posttraining changes in physician counseling behavior, independent samples of patients with obesity were surveyed immediately after their visit to the physician's office. Physicians in both the counseling skills training and the control groups discussed weight with 42% to 47% of their patients at baseline. This increased to 89% in physicians who received training, whereas it remained at 42% in control physicians. Scores on a counseling measure also significantly increased from a mean of 2. 7 to 9. 9 in the counseling group, whereas scores in the control group remained low and stable (2. 3 and 1. 9, respectively). The training program was effective in improving the frequency and quality of counseling that physicians delivered to their patients with obesity. Future research is needed to evaluate the effect of physician counseling on the weight and physical activity level of their patients.     

Obesity and the Use of Health Care Services

Objective: This study investigated differences in the use of health care services and associated costs between obese and nonobese patients. Research Methods and Procedures: New adult patients (N = 509) were randomly assigned to primary care physicians at a university medical center. Their use of medical services and related charges was monitored for 1 year. Data collected included sociodemographics, self‐reported health status using the Medical Outcomes Study Short Form‐36, evaluation for depression using the Beck Depression Index, and measured height and weight to calculate BMI. Results: Obese patients included a significantly higher percentage of women and had higher mean age, lower mean education, lower mean health status, and higher mean Beck Depression Index scores. Obese patients had a significantly higher mean number of visits to both primary care (p = 0.0005) and specialty care clinics (p = 0.0006), and a higher mean number of diagnostic services (p < 0.0001). Obese patients also had significantly higher primary care (p = 0.0058), specialty clinic (p = 0.0062), emergency department (p = 0.0484), hospitalization (p = 0.0485), diagnostic services (p = 0.0021), and total charges (p = 0.0033). Controlling for health status, depression, age, education, income, and sex, obesity was significantly related to the use of primary care (p = 0.0364) and diagnostic services (p = 0.0075). There was no statistically significant relationship between obesity and medical expenditures in any of the five categories or for total charges. Discussion: Obesity is a chronic condition requiring long‐term management, with an emphasis on prevention. If this critical health issue is not appropriately addressed, the prevalence of obesity and obesity‐related diseases will continue to grow, resulting in escalating use of health care services.     

严重急性呼吸综合征冠状病毒2变异体对全球疫情防控的影响分析

由严重急性呼吸综合征冠状病毒2（SARS-CoV-2）引起的新型冠状病毒肺炎（COVID-19，简称新冠肺炎）的出现，对国际公众健康构成了严重威胁，伴随COVID-19大流行而来的是SARS-CoV-2基因组的不断突变，尤其是受关注的变异体（variants of concern，VOCs）给全球COVID-19疫情防控带来了挑战。本文综述了SARS-CoV-2的突变情况和现阶段主要流行的VOCs的特征，总结了现有及潜在的COVID-19预防、诊断和治疗手段，并通过分析SARS-CoV-2变异体对全球COVID-19疫情防控措施的影响，提出合理的建议，以期为今后可能爆发的大范围流行病的防控提供理论依据。