Health: Obesity
Discussion About Overweight and Obesity in the District's Latino Community

Meredith Susan Josephs, M.D., M.P.H.
Medical Director, La Clinica del Pueblo
Friday, January 20, 2006 2:30 PM

Dr. Meredith Susan Josephs, medical director of La Clinica Del Pueblo in Washington, D.C., was online Friday, Jan. 20, at 2:30 p.m. ET to discuss the prevalence of and treatment for overweight and obesity in the District's Latino Community and her work at the health facility. La Clinica del Pueblo in Northwest provides free health services to Latinos.

As Medical Director of La Clinica del Pueblo since 2000, Josephs provides clinical and administrative services for the health center. She received a M.P.H from The George Washington University, with an emphasis in community oriented primary care. Josephs received a M.D. from the University of Maryland School of Medicine.

In Tuesday's health section in The Washington Post, staff writer Krissah Williams reported on the prevalence of obesity in the District's Latino Community:

"According to the 2005 National Health Interview Survey of the Centers for Disease Control and Prevention (CDC), at least one of every four Hispanic adults living in the United States is obese, which is defined as having a body mass index, or BMI, of 30 or more.

"Among the major population categories, only non-Hispanic black women, a group in which at least every one of three is obese, have markedly worse figures. But in some sub-groups, notably Mexican-Americans, the problem is worse than in the Latino population as a whole -- and growing, particularly in children.

"Obesity is leading to health problems, according to a 2003 American Medical Association study, which found that Hispanic children under age 10 have about a 50 percent lifetime risk of developing type 2 diabetes. Overweight and obesity also increase risk for other illness, including heart disease, stroke, and certain forms of cancer.

"A study released in September by the District's Council of Latino Agencies assessed the health of Washington's Hispanic community (population 47,258, according to the 2000 Census). The study -- which involved 800 Latino adults, 99 percent of whom were recent immigrants -- found that 61 percent were overweight or obese. Community activists now are struggling to change habits that may contribute to this problem ..." ( Read More .)

The discussion transcript follows.

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Meredith Susan Josephs, M.D., M.P.H.: Good afternoon,

I'm Dr. Josephs, the medical director of La Clinica del Pueblo. I'm excited to be with you today to talk about the epidemic of obesity in the Latino community.

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Arlington, Va.: How did you get involved in your work at the health center? What are some other clinics like it? Thanks.

Meredith Susan Josephs, M.D., M.P.H.: I have always had an interest in working with underserved communities. Having spent time in Guatemala I developed an appreciation for Latino culture. Upon completion of my Family Medicine Residency training, it seemed natural to look for work within the Latino community.

I joined La Clinica as a staff physician in 1998 and became its Medical Director in 2000.

There are many safety net clinics in the DC metropolitan area. While all are dedicated to serving those most in need, each has its own style and spirit and target population.

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Washington, D.C.: Do you think obesity is a cultural problem?

Meredith Susan Josephs, M.D., M.P.H.: This is an interesting question. Will you please elaborate? Thanks.

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Alexandria, Va.: As a doctor do you consider the gastric bypass surgery a healthy option for obese patients you speak to or do you encourage more of lifestyle change that includes healthy diet and exercise?

Meredith Susan Josephs, M.D., M.P.H.: As a family physician working with the uninsured, I don't have the option of offering gastric bypass surgery to my patients since they don't have the means to pay for elective surgeries.

However, given the risks of surgery and anesthesia I often recommend to my patients that surgery in general be considered as a last resort.

Poor lifestyle choices contribute to and exacerbate obesity and it should therefore be treated initially with lifestyle changes. This is the mainstay of treatment even for those who have the ability to pay for expensive weight loss medicines and surgery.

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Washington, D.C.: Do you think cultures influence obesity and if so, in what way? How does the Latino culture, for instance, impact obesity within the community itself? Thanks again.

Meredith Susan Josephs, M.D., M.P.H.: Culture influences our food choices, our activities, and our body images. Each community/culture has norms which it values and ideas about what to eat, when to eat, where to eat, etc.

The Latino community in DC is an immigrant community. It is learning to live and adapt in a foreign culture. We see obesity in the immigrant Latino community, but not as frequently in Latino's home countries.

This is a complex issue. I believe that what we see here is a result of an immigrant community adjusting to living outside of their traditional environment.

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Culture and Obesity: I am not the original poster, but I believe that obesity is definitely a cultural problem! Americans are fat because we drive everywhere, watch too much TV and eat too much fast food in gigantic portions. When I lived in Asia 15 years ago, I rarely saw any heavy people. But fast food restaurants are becoming increasingly popular there, and I noticed more and more children getting fat. When I returned last year I was shocked at how many more heavy people I saw. I also feel that there is much less of a stigma for Hispanic and African American women to be heavy. It is much more accepted by their men and these women seem to have a better self body-image than white women. I am from a Spanish family, and life revolves around food. When I was a child my grandmother would get upset if we didn't eat a ton of food and will tell my mom we were too skinny (and I was chubby!)

Meredith Susan Josephs, M.D., M.P.H.: Thanks for specific examples of culture clashes' impact on communities. I agree with the points you raise.

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Washington, D.C.: In the article it states that the woman who changed her eating habits saw an increase in her grocery bill because of buying more fruits and vegetables. Do you see this as an issue in families attempting to change their eating habits due to the fact that fast food is cheaper and is seen as getting more for your money than going to a health foods store?

washingtonpost.com: Lightening the Burden (Post, Jan. 17)

Meredith Susan Josephs, M.D., M.P.H.: Absolutely. I live in the same neighborhood as our clinic. I have noticed that fresh fruit and vegetables at the supermarkets are more expensive (and of poorer quality) than those found in suburban supermarkets.

And there are many,many fast food restaurants around which make it both convenient and cheap for purchasing meals.

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Bethesda, Md.: Do you think obesity will eventually take its toll on Americans average life span? Do you think we are nearly "maxing" our life spans out now and they will begin to fall? Obesity is increasing as well as diabetes, heart disease, etc., at an alarming rate and while the number of amazing pharmaceutical therapies are also increasing it's also more expensive for patients to get these medications.

Meredith Susan Josephs, M.D., M.P.H.: Absolutely. Obesity is a medical condition which contributes to high blood pressure, diabetes, and heart disease - all major killers. Studies show that patients with higher BMIs (Body Mass Indices) have a shorter life span and also a poorer quality of life.

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Baltimore, Md.: Do any insurance companies reimburse primary care physicians for counseling on weight management issues? It seems like this would be as important or more important than other billable components of a visit, but the issues are so complex that it would be hard to fit into a patient's yearly physical.

Meredith Susan Josephs, M.D., M.P.H.: Counseling about lifestyle issues is important, complex, and takes time. I agree that this type of counseling should be reimbursable.

At La Clinica, our patients are uninsured. I therefore don't know if insurance companies are currently reimbursing for this service.

Because Latinos are uninsured at higher rates than any other ethnicity, fewer Latinos have access to medical care that is governed by industry standards.

We pull resources together from anywhere we can in order to provide comprehensive quality care to our patients,including the counseling you mention.

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Washington, D.C.: What type of services does La Clinica offer its obese patients?

Meredith Susan Josephs, M.D., M.P.H.: In addition to providing comprehensive primary care to obese patients, La Clinica has several services that are focused specifically on helping patients make lifestyle changes that will help them lose weight and reduce their risk for obesity-related conditions. All medical providers conduct nutritional and exercise counseling for patients with a BMI (body mass index) that indicates that they are overweight or obese. A doctor may, for example, encourage a patient to incorporate more vegetables into his or her diet. In addition, a health educator is available to work one on one with patients who struggle to make these changes.

Providers also focus on incorporating exercise into patients' daily routines. Few La Clinica patients have the economic resources to enroll in a gym or fitness center, but providers advise patients to make small changes like walking instead of taking the bus, for example, to help incorporate physical activity into their lives. La Clinica also recently formalized a collaboration with Curves, a local fitness center for women.

Obese patients also suffer from a variety of obesity-related conditions, such as diabetes, high blood pressure, heart disease, or musculoskeletal ailments, so at La Clinica we help manage these conditions within a primary care setting. All patients have access to mental health counseling as well, which is important since depression many motivate patients to overeat. If you'd like more information on the services available at La Clinica, please visit our Web site at www.lcdp.org.

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Alexandria, Va.: How do most people hear about your clinic? Word of mouth? Or do you advertise strategically?

Meredith Susan Josephs, M.D., M.P.H.: La Clinica patients mostly learn about us through word-of-mouth, however we have had difficulty seeing all of the people in need of services. We have even had to turn away family members of existing patients because we simply don't have the resources to serve all those requesting services.

La Clinica has been around for over 20 years and has a reputation for being a safe place in the Latino community. We wish we could serve everyone because there is so much need.

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N.Y.C: Do you feel that some people are just destined to be obese (genetically)? I have a 400-pound friend who insists that it is impossible for her to lose weight. However, I see the amount of food she eats and her sedentary behavior and I know she isn't even trying. I am pre-disposed by genes to be heavy. If I ate the same amount of food each day as my skinny best friend, I would be huge. However, I am aware of this and I eat right and make sure to work-out almost every day. I am at a normal weight, but it is a constant struggle. I think obese people sometimes hide behind the excuse of genetics in order to avoid changing their lifestyle. I can completely sympathize, because I know firsthand how difficult and frustrating it can be.

Meredith Susan Josephs, M.D., M.P.H.: Yes, genetics contributes to our physical and emotional health. As you've said, you struggle to keep your weight in a healthy range. Others, with a different genetic make-up, are lucky enough to be able to eat what they choose without worry.

Genetics predisposes certain people and populations to obesity (among other diseases), but environmental factors are just as important contributors to obesity. Studies of immigrant communities have shown the longer an immigrant is in this country, the more likely they are to be obese. There is a correlation with BMI and years lived in the US.

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Reston, Va.: I was diagnosed with type 2 diabetes 8 years ago and had to change the way I eat - and I'm now under control. I ate at fast food restaurants far too often and ate prepared/frozen foods too often. I was shocked at how unhealthy damaging this "commercial" diet was! (See film "Super Size Me").

One of the healthiest things we could do as a nation would be to make a healthy diet available via better prepared foods at the supermarket and at convenience restaurants, and provide better education. To eat well now, Americans need to prepare (at least for me) complicated recipes!

Meredith Susan Josephs, M.D., M.P.H.: Although I am still waiting for "Super Size Me" from netflix, I do agree with your point. I wish that we could get a Spanish version of the movie to show in our waiting room!

I always teach my patients that home-cooked meals are healthier than anything ready-made. And I don't know that the recipes need to be that complicated to be healthy. The complicated ones probably look and taste better though.

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Washington, D.C.: What do you think are the three most important community action steps that could be taken to address the problem of obesity in the Latino community?

Meredith Susan Josephs, M.D., M.P.H.: Great question!

Looking at the issue from a public health perspective, communities should focus on three levels of prevention:

1. First and foremost, making sure grocery stores in all neighborhoods are available and carry nutritious foods at a reasonable price.

2. Ensuring that communities have sidewalks, parks, rec centers, bike paths, gyms, and other safe spaces for people to participate in physical activity; and maximizing the opportunities for involvement in healthy activities by making sure that programs can serve bilingual populations.

3. Ensuring that all individuals have access to preventive health services, regardless of their income level or the language they speak. Everyone should have a primary care provider that can speak to them regarding their risk for obesity and what changes they can make to avoid the complications associated with overweight and obesity.

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Meredith Susan Josephs, M.D., M.P.H.: Thanks for the thoughtful questions. Please refer to our web site www.lcdp.org for more information about our organization and the community we serve.

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