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.

The ethnic populations at higher risk are Hispanics, African-Americans and Native Americans, Dr. Jafri continues, noting that the mentally ill "seem to be at risk as well due to their mental illness, and due to some of the newer medications that can actually cause metabolic syndrome and diabetes." Patients with diabetes have it particularly hard as some of the medications used to treat it can also cause weight gain. And in general, immigrant populations are at higher risk as they assume Western eating habits and give up their native foods and generally healthier diets. That's why Southern California is an emerging hot spot for obesity.

Indeed, the numbers are just ghastly. In 1986, according to the U.S. Centers for Disease Control and Prevention, just half a dozen or so states reported that more than 10% of their populations were obese. Higher rates were generally confined to states with the largest urban areas, but California fell into the "less than 10%" category. By 1996, around the time obesity really started to show up on public health officials' radar, no state could claim that less than 10% of its population was obese--but no state had yet crossed the 20% barrier. In the CDC's 1996 numbers, California had risen to the 10% to 14% obese category. Now California falls into the 20% to 24% obese category, along with the rest of the West and the Northeast. Most of the Great Plains and, famously, the South, fall into the 25% to 29% obese category, the CDC's data say. Just four states can claim that less than 20% of their populations are obese, while Mississippi and West Virginia hold the crown for the most-obese states: At least 30% of their residents have a Body Mass Index over 30, which is defined as obese.

That's how public health officials calculate obesity. For children and adolescents, the American Medical Association recommends, BMI values are calculated on the CDC's age-adjusted growth chart; a BMI that falls in the 85th to 84th percentile is considered "overweight"; over the 95th percentile is "obese." For adults, a BMI below 18.5 is considered underweight for adults. If your BMI is 18.5 to 24.9, you're at a healthy weight. When your BMI rises to the 25.0 to 29.9 range, you're overweight, and if it's over 30, you're obese. Over 40, and you're morbidly obese. Say you're 6 feet tall and 150 pounds. Divide your weight in pounds by your height in inches squared. Since 72 squared is 5148, divide 150 by 5148 and you get .029. Multiply that by 703 for a BMI of 20.5, or right in the middle of "healthy." Add 50 pounds and the BMI rises to 27.3; that's "overweight". At 250 pounds, that same six-footer is "obese," with a BMI of 34.2.

That's why the CDC's latest research came up with this frightening statistic: "More than one-third of U.S. adults"--those age 20 and over, or more than 72 million of us--"were obese in the 2005-2006 study period, including 33.3% of men and 35.3% of women," the CDC says in a famous November 2007 Data Brief. That means as many as 1 million people crossed the line into "obese" from the time of the CDC's 2004 numbers. Another study pegs the number of "overweight" Americans at something like 175 million--and overweight can lead to obesity. As well, results from the 2003-2004 National Health and Nutrition Examination Survey show that an estimated 17% of children and adolescents ages 2-19 years are overweight. In California, one report points out, the prevalence of overweight children doubled in the last 20 years, and the overweight rate among adolescents tripled. Californians' collective chubbiness--an adult obesity rate of 22.7%--places us 30th in the nation, wedged between Delaware and a tie between Idaho and Washington, and we're one of 31 states where obesity rates rose in the past year. No state experienced a decrease. Mississippi is the heaviest state, the CDC says, with an adult obesity rate of 29.5%, and Colorado is the skinniest, with an adult obesity rate of 16.9%. Regionally, the South is home to nine of the 10 states with the highest rates of obesity.

Inside California, county-level apples-to-apples obesity data is hard to come by, because definitions vary and because public health officials often measure overweight and obesity combined, looking at the increased health risks faced anyone with a BMI over 25. The California Health Interview Survey, conducted periodically by the University of California at Los Angeles, found that adult obesity rose from 19.3% statewide in 2001 to 21.2%--or close to 6 million of us--in 2005. For adolescents, the rate rose from 12.4% in 2001 to 14.2% in 2005. In the 2005 CHIS data, Imperial County tops the state, with an "overweight or obese" percentage, for adults and adolescents, of 62.5%, reports Diana Soltero Grill, MPH, an epidemiologist with the Ventura County Public Health Department. That's two-thirds of the population there. It's probably no surprise, given numerous studies that correlate ethnicity with rates of obesity, that Imperial has the highest percentage of Latino residents--72 percent--in the state and, in 1999 anyway, 29% of the population lived at or below the federal poverty level, compared to 16% for the entire state. The Latino Coalition for a Healthy California says seven in ten Latino adults in the state are overweight or obese, and Latinos are the fastest-growing segment of our population. Riverside County ranks 9th for combined adult and adolescent overweight and obesity in the CHIS data, with a rate of 57.4%, followed closely by San Bernardino County, at 57.2%. Both Ventura County, at 52.6%, and Los Angeles County, at 51.4%, fall roughly in the middle. Orange County ranks 53rd, with a rate of 44.7%. Combined, these six Southern California counties post a rate of 50% to 52%, or about the same rate as the entire state.

Percentages of Overweight and Obese Adults by County
Imperial* 62.5%
Riverside 57.4%
San Bernardino 57.2%
Ventura 52.6%
Los Angeles 51.4%
Orange 44.7%
*Highest in the state of California according to the 2005 California Health Interview Survey.

Drilling down, some fascinating snapshots emerge. A 2003 press release from Ventura County notes that "to most of the world, the Gold Coast is a paradise, replete with sun, surf, scenery and endless recreational opportunities," but that health statistics point to a far different reality. In its 2005 data, the county reported an adult obesity rate of 16.6%, with an overweight rate among low-income children of 24.6%. Los Angeles County tabulates childhood obesity community-by-community. Using admittedly small sample sizes, the Public Health Department reports a county low in Monrovia of 2.8% and a whopping high in Irwindale of 40.9%. Countywide, the worst childhood obesity centers in the San Gabriel Valley and Central and South Los Angeles. Adult obesity rates are highest among Latinos, at 29%, African-Americans, at 28%, whites, at 17%, and Asians, at 6%. Interestingly, three years earlier, the adult obesity rate for Latinos was 24% and that for African-Americans was 31%. For their parts, obesity rates in Riverside and San Bernardino Counties increased almost four times as fast as state rates--and more than twice as fast as national rates--from 1996 to 2006, one study says. Nearly a third of Riverside County and San Bernardino County residents were obese in the report.

If there were easy answers, of course, Southern California doctors would already have taken care of the problem, and the region wouldn't be getting so much fatter. "Most of the burden falls on the primary care doctors, but they don't have the resources needed to provide for effective intervention," Dr. Jafri points out. "Indeed, most doctors don't know what to do for their obese patients unless they have a special interest or expertise. They usually provide some services, but not always what is optimal for the patient." That's because obesity treatment requires a broad, comprehensive approach that encompasses medical, nutritional, lifestyle and behavioral intervention; the most advanced cases may require drugs or surgery, too. "The uninsured certainly are at highest risk, and the burden of treatment falls on the public-supported healthcare systems," Dr. Jafri explains. "The hard part about obesity treatment is it is a difficult problem that takes years of commitment to get results that will last. Patients and doctors often do not seem to understand that and give up too early in the program."

The time commitment required to see results is one of the reasons obesity is tentacling itself into medical practices that, in a healthy world, would hardly ever need to bring up the "O" Word. Encino-based anesthesiologist and interventional pain management specialist Jeffrey B. Glaser, MD, for example, notes that, from an anesthesiologist's perspective, there's not much he can do except note to patients that obesity brings co-morbidity factors that increase the likelihood of complications and the general risk of anesthesia, including more difficult intubation and post-op breathing and respiratory problems. In his pain management practice, he adds, a growing number of his patients have underlying degenerative disc disease exacerbated by morbid obesity. "I'm seeing more and more obese patients every year," Dr. Glaser says. "I discuss with them the risks of morbid obesity and how it complicates their conditions and makes them more difficult to treat."

Hoag Memorial Hospital-based surgeon Jay Ross Zubrin, MD, sees obesity from the perspective of an "outsider" as well. About 90% of the Newport Beach doctor's patient load is emergency cases, he notes, so he almost never has the luxury of counseling patients about how much more dangerous surgery is for the obese, and even when he does, waiting is often the last thing the patient's primary condition needs. "With obese patients, surgeries are more difficult for me and higher-risk for them," he says. "But if the need is acute, I can't wait until the patient loses weight." Even if the surgery isn't urgent, waiting for a patient to lose weight generally isn't an option. "You're better off operating before the condition gets worse," he adds.

Practically every patient Rodney Borger, MD, sees is an emergency patient, too. He's medical director of the Emergency Department at Arrowhead Regional Medical Center in Colton. And Southern California's obesity epidemic has touched his practice as well. He sees a lot more obese patients than he did in years past, and they tend to have more--and more severe--medical problems than they used to. Just recently, he treated a 16-year-old female who presented with high blood pressure and diabetes--both related to the fact that, at 5'4", she weighed 275 pounds. That's a BMI of 47. "Part of being a doctor is talking to patients like her about her weight," Dr. Borger says. "But the detailed counseling and continuity of care someone like her will need should come from a single physician who can follow her case. That's difficult with the access-to-care issues we have here." There are more mundane ways obesity affects emergency medicine docs, Dr. Borger adds. "Medical equipment is not set up for people over 350 pounds," he explains. "CAT scans and MRIs are very, very difficult. Sometimes impossible. Even finding a wheelchair, a gurney or a hospital bed is difficult. So is trying to move a patient."

The thing is, obesity intervention works, when there's time for it, and doctors are in a unique position to intervene. But the barriers are sometimes, frankly, all but insurmountable. One of the culprits, unfortunately, is a familiar one to many doctors. "Obesity is the root of many of our most severe health problems, yet insurance coverage is abysmal," says Harold W. Jackson, DO, president of the Riverside-based Raincross Medical Group. "Hypertension, hypercholesterolemia, diabetes and even many cancers are more common in obese people, but the counseling resources and possibly helpful medication and exercise assistance programs are generally not covered. Insurance companies are too busy becoming obese with profits to help obese people with this major health problem. And it is unlikely the situation will change as long as big business and the profit motive are positioned between patients and healthcare." That's tragic, Dr. Jackson emphasizes, because the right intervention can achieve results. "I have a very few patients who really diet and really exercise and experience very good weight loss," he says. "How they are able to make that change in their lifestyles is unclear, but that's what we need to work on. We need to learn what the barriers to change are in each person and then treat those barriers specifically."

There's the problem, right there. When it comes to obesity, we're a region of barriers to change, when you get right down to it. We have gastronomic cultural heritages that often don't blend particularly well with available food supplies. We have a diverse linguistic culture that often makes understanding the nuances of diet and exercise recommendations from a doctor who speaks a different tongue next to impossible to understand fully. And we have access-to-care issues worsened by the fast-changing entrepreneurial economy we're so proud of here. But we practically invented reinvention in Southern California. Here's a chance for doctors to reinvent the way they approach obesity and thus help their patients reinvent themselves.
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SIDEBAR: Getting Started: Resources
Obesity prevention and treatment is as complicated
as medical care gets. Here are a few educational and informational resources recommended by Christine Maulhardt, director of obesity prevention at the Sacramento-based California Medical Association Foundation:

-The CMA_Foundation offers a community resource directory, policy advocacy support and up-to-date
news and research on its website at www.calmedfoundation.org/projects/obesityProject.aspx.

-The Centers for Disease Control and Prevention
offer information about BMI, online calculators, links to additional BMI resources and growth charts at www.cdc.gov/nccdphp/dnpa/bmi/index.htm.

-These free downloads for use on Palm OS and Pocket PC provide information on BMI and adult BMI classification tables: hp2010.nhlbihin.net/bmi_palm.htm.

-The CMA Foundation's Adolescent Health Working Group offers "Body Basics," a toolkit that includes materials for providers and their patients focusing on nutrition, physical activity, body image, overweight and eating disorders among teenagers. Find it at www.ahwg.net/resources/toolkit.htm.

-The American Medical Association, at www.ama-assn.org, offers a ten-booklet CME program called "Roadmaps for Clinical Practice-Assessment and Management of Adult Obesity."

-The American Diabetes Association, at www.diabetes.org, offers a two-hour CME program called "Clinical Management of Obesity: With Special Attention to Type 2 Diabetes."

-Also, Discovery Health CME, at ww.discoveryhealthcme.com, offers these video CME programs: Bariatric Surgery: Weighting the Options, Adult Obesity: Reversing the Trend, Childhood Obesity: Combating the Epidemic, Healthy Steps to Treating Childhood Obesity, Eat Right, Live Right.

-Finally, "Overweight & Obesity in Childhood Prevention & Management," sponsored by the CMA Foundation and WellPoint, has been approved for 1.5 AMA PRA Category 1 credits. Find details at www.eventstreams.com/wellpoint/010rde/.

SIDEBAR: The Problem with Kids
Of course, the most tragic element of the obesity epidemic is how hard it's hitting kids. "Obesity has a somewhat higher incidence in Hispanics and African-Americans, but pretty much every ethnic group is at increased risk," says Steve Tarzynski MD, MPH, chief of pediatrics at Kaiser Permanente West Los Angeles. "In the last 30 years, it has more than doubled for pre-school children, those 2 to 5 years of age, and for adolescents, those 12 to 19 years old." It's more than tripled among those 6 to 11 years old. And that's why he brings up the issue during every regular physical exam. But he doesn't bring it up during all urgent visits. "It's very time-consuming to address obesity, and I cannot have other patients waiting more than they already do," Dr. Tarzynski points out. If there's time, or the issue is pertinent to the urgent care visit, he does make time. One advantage kids have is their parents' growing focus on obesity. "Cultural issues are not as important as they used to be, because most children have second-generation parents or immigrant parents who are aware of the obesity problem," he says. "In the last two years, I've seen a big shift--parents are much more worried about obesity. For once we can thank the media for being helpful."

SIDEBAR: When Dieting Just Doesn't Work
If Star Jones Reynolds can cop to stomach surgery as a weight loss treatment, then it must be the Obesity Procedure of the Stars! This is Southern California, after all. But as is the case with much of the mythology of the region, the reality of alternative therapies for obesity--those that don't focus simply on consuming less, exercising more and understanding why you eat the way you do--is they do have a great deal of merit. Surgery, especially, is becoming almost commonplace.

"Drug therapy does not offer good support long-term without behavior and lifestyle changes, as patients tend to gain all the weight back as soon as they stop the drugs," Dr. Jafri comments. "Still, they are helpful to get patients motivated to get a jump start on the changes they plan to make." Surgery, she notes, is generally recommended for the morbidly obese or those with moderate obesity and multiple additional risk factors, such as diabetes, arthritis or heart disease. "There are studies showing improved survival and longevity with surgery," she says. "All the programs I'm aware of require patients to lose 10% or so of the weight on their own first. Also, Medi-Cal and other insurance programs require enrollment in a one-year program for weight loss before they will approve surgery." Many surgery programs have a component of psychological assessment and counseling built in, she adds. Comments border health expert James T. Hay, MD,: "Surgery works. Several of our office MAs have done very well, and insurance coverage is much better than it was a few years ago. There are risks, though, so surgery should be reserved for the morbidly obese and who have failed more conservative attempts over a significant period of time."

Suzy Prudden, a personal success coach and fitness and body/mind expert--who also works as a hypnotist at Los Angeles--area Positive Changes Hypnosis Centers--sees an increasing number of patients for whom even surgery didn't work. "We rarely get the severely obese," she points out. "Our clients average having to lose between 25 and 150 pounds. Unfortunately, we've had people come in who've done the surgery and lost the weight, only to gain it back and end up on our doorstep." More doctors, she adds, are "recognizing that hypnosis is the best support for someone who needs to lose weight. We're getting more referrals from physicians." It's not for everyone, of course. "Some people come in because their doctors told them to come, but they really don't want to change," she says. "The best client is the one who really wants to make the changes that will help him or her lose weight, keep it off, get healthy and experience freedom from obesity." She likes to tell the tale of a client who just completed her program after two years. "She lost 105 lbs," Prudden boasts. "It was slow and steady. The best client is the one who keeps showing up and doing what is right for his or her body.