Conjure up a mental picture of Southern Indiana. A tricky one, perhaps, because you've probably never been there. It's quite scenic, with gently rolling hills and leaves that turn lovely reds and yellows in the fall. Now try South Florida. Much easier: the pulsing nightlife of South Beach and the tropical island beauty of the keys. Now the easiest one of all: Southern California. Palm trees. Glinting sunshine. And, likely, a fit, energetic Brad Pitt type or, even more likely, a luscious blond in the Pamela-Anderson-in-"Baywatch" mold. Indeed, unless you're thinking about Kirstie Alley or perhaps Chas Bono, the notion of "obese" probably doesn't color your hot-bodies-and-incredible-beaches Southern California mental imagery.

But it should.

As the obesity epidemic spreads across America, it's becoming increasingly apparent that two of the most at-risk subpopulations are ethnic minorities--Latinos and blacks, in particular--and the uninsured. Sound familiar? That's Southern California in a nutshell. Our rich tapestry of cultural diversity and, unfortunately, our crazy health insurance market combine to make us a region with an obesity problem that's not as severe as it in the South--yet--but one that's getting worse faster than in many other areas of the country. Doctors who specialize in the types of services typically associated with obesity interventions--family practice doctors and pediatricians, in particular--are changing their approaches to treatment in light of the skyrocketing number of patients they see with weight issues. And those who don't often get involved in obesity interventions--dermatologists, say, or eye doctors--are bracing for a future filled with many more conversations that start with, "Have you talked to your primary care doctor about your weight?"

That is certainly the case for pulmonologists, reports Richard Frankenstein, MD, FACP, a Garden Grove-based pulmonary disease specialist and president of the California Medical Association--even though most of his patients are at the opposite end of the body mass spectrum from the obese. "They're old and very skinny, for the most part, and many are almost emaciated," he reports. "But if they're not, I ask how far they walked from the car to the office." For a lot of specialists, obesity is still a little remote, he acknowledges. "We're not yet at the point where it's part of every medical encounter." But it will be. "Obesity is an example of an issue where every doctor needs to be involved," Dr. Frankenstein urges. "Already, there's more awareness of it and the challenges it poses to every physician's practice."

"Awareness," yes. In some places in Southern California, "awareness" of obesity is starting to impact practices in very real ways. But for Asma Jafri, MD, chair of the Department of Family Medicine at the public Riverside County Regional Medical Center, Moreno Valley, simple "awareness" of obesity is soooo 20th Century. Today, it's already part of the DNA of her practice. "I have certainly changed the way I approach obesity with my patients and how I teach the obesity topic to medical students and residents," she reports. "I bring it up more often with patients during their general health visits and visits for chronic diseases like hypertension, heart disease and diabetes. And if a kid is overweight, I tell the parents about the risks for the child now--and about the future risks as the child grows up." Dr. Jafri's recommendations cover healthy lifestyles and nutrition--and it starts as soon as the patient is born. "I start out with nutrition at the newborn stage with breastfeeding recommendations over formula and then healthy snacks and nutritious meals that can be prepared at home without undue hardship for busy families," Dr. Jafri says. "I talk about restrictions on TV and the importance of play activities both indoors and out."

Obesity has, she says, replaced smoking as "the number one preventable cause of death in our country." Like smoking, she notes, obesity tends to hit hardest at the Southern Californians who are least equipped to hit back. "It's especially challenging for those of us who work in the public sector, as we see most of the underprivileged and underserved--in terms of both financial and educational resources--in our society," she says. "They have the most limited resources and certainly cannot afford the commercial weight-loss programs." The issue is complicated by the fact that healthy foods--like fruits and vegetables, lean meats and fish and whole grains--are more expensive than processed foods and snacks such as chips, sodas and cheeseburgers. "Some fast food menu items are large enough to provide calories for the whole day with one item," Dr. Jafri laments. "Have you seen the 'Super Size' choices of soda and French fries?" Super, indeed.