skip navigation

CHS Research News
Vol 18, Issue 2, Spring 2006

Feature Article

Dr. David Arterburn:
Leading CHS research on weight management with behavior change, nutrition, and physical activity

By Rebecca Hughes

It was while living in San Antonio, Texas—then the third “fattest” city in the nation—that David Arterburn, MD, MPH, first became interested in obesity research. “I personally slowed down slightly because of the hot weather and delicious tamales, so I thought those might be the culprits,” he jokes.

His more rigorous research with the South Texas Veterans Affairs (VA) health services research and development field program on obesity pharmacotherapy led him to pursue a career in this area. Arterburn recently joined Group Health Center for Health Studies as an assistant investigator. He is opening up a new area for the Center: obesity health services research. He is exploring which approaches are really effective—and cost-effective—at preventing and treating obesity over the long haul, and which are not.

It’s serious business, addressing “one of the most complex and expensive health problems in the United States, which keeps becoming more common,” says Arterburn. Two thirds of Americans are now overweight, defined as having a body mass index (BMI) of 25 kg/m² (169 pounds for a 5’9” adult) or more. BMI is weight in kilograms divided by height in meters squared. For the metrically challenged, the National Institutes of Health has developed a Web page to help with the conversions.

“We’ve got to do something about this epidemic,” he says. “But our biggest challenge is in figuring out how to motivate behavior change over the long term.”

Which interventions work?

Arterburn has developed distinctive expertise in using systematic reviews to determine which interventions really help treat and prevent obesity safely and effectively. His pharmacotherapy reviews in this area have formed the backbone of clinical practice guidelines issued by the American College of Physicians, the Department of VA, and the U.S. Preventive Services Task Force. He also currently serves as a medical editor for the Foundation for Informed Medical Decision Making, and is working with the Foundation to develop video-based shared decision-support tools for obesity interventions.

The first intervention for most people is to increase their physical activity, says Arterburn. The less active you are, the more it will help to add even a little activity to your life. Obesity, which kicks in at 30 kg/m², or 203 pounds for a 5’9” adult, limits physical activity for some people, he says. But he adds that the “fit fat”—people who are physically active despite being overweight—have fewer health risks than they otherwise would. The other piece of the puzzle is controlling total calories, he says. As for the seemingly endless debates over relative proportions of macronutrients—protein, fat, and “carbs”—he won’t even go there: “We really don’t have enough evidence to recommend one diet over another, and the media debate over macronutrients is very confusing to most people,” he says. “The evidence shows it’s mostly about reducing caloric intake.”

Various interventions—including meal replacements, weight loss drugs, and bariatric surgery (such as gastric bypass)—hold promise for some adults with extreme obesity, says Arterburn. (Extreme obesity is defined as having a BMI of 40 kg/m² or more, or generally at least 100 pounds overweight.) However, his systematic reviews have concluded that current interventions strike a delicate balance between benefits and harms.

Bariatric surgery seems the most effective way to promote substantial long-term weight loss in people who are extremely obese, improving chronic health conditions for up to five years and letting them become more active physically. But he says up to 2 percent of patients die within 30 days of the surgery, and up to 20 percent risk postoperative complications. Within two to four years after surgery, patients’ behavioral issues tend to start re-emerging, and some patients regain all of their weight. “This surgery is not for everyone with extreme obesity,” he cautions. “We don’t know enough about the long-term cost consequences.” One example of how Arterburn is trying to address gaps in the evidence base is his recently funded study of long-term survival, health care use, and costs for more than 1,000 people who have had bariatric surgery through the VA system, nationwide, from 2000 to 2006.

The bottom line, says Arterburn: Whatever the intervention, when it ends or its intensity wanes, the weight gain starts up again. The research community is finally starting to pay attention to this issue. “We need to find ways to help people maintain their weight loss—or just to stay at their current weight, without gaining,” he says.

Here come the ‘obesity boomers’

Arterburn has published articles on obesity’s impact on health outcomes, health-related quality of life, use of health services, and costs of care. His work has indicated that obesity was associated with over $50 billion in total US health care expenditures in 2000; and that the number of obese elderly people will more than double from year 1990 to 2010 in the United States.

It’s no secret that as people age, they tend to pack on more and more weight. This trend used to reverse as people entered their 70s. But Arterburn’s analyses have shown that now, not only are successive generations starting out heavier and then gaining more weight, faster; their weight gain is also continuing even through their 70s.

“The rising prevalence of obesity among the elderly is the most surprising and concerning thing I’ve found,” he says. “We’re faced with the baby boomers, who will be the largest cohort of retirees ever. They’re also likely to be the ‘obesity boomers.’”

The health care system has gotten better at treating the diseases that are associated with obesity, such as diabetes, high blood pressure, and heart disease, says Arterburn. So obese people are living longer, with more expensive chronic health conditions and greater limitations on their ability to function. This is placing a burden on Medicare, long-term care, and health plans such as Group Health.

Multidisciplinary collaborations at Group Health and beyond

In joining the Center, Arterburn will collaborate with other Center investigators, including CHS Associate Director and Associate Investigator Katherine Newton, PhD; and Senior Investigator Greg Simon, MD, MPH. “This is a really good environment for me to do my work,” says Arterburn. “The timing is right for Group Health to be pushing hard on effective prevention of obesity.”

Arterburn serves with CHS Senior Investigator and Medical Director of Group Health Permanente’s Department of Preventive Care (DPC) David Grossman, MD, MPH, and Assistant Investigator Robert Reid, MD, PhD, on the Healthy Lifestyle Committee that Group Health Family Practitioner and CHS Affiliate Investigator Elizabeth Lin, MD, MPH, chairs in DPC. With them, Arterburn is developing clinical practice guidelines and a toolkit for providers around weight management and physical activity; and they are trying to determine what is—and isn’t—working with the weight management programs that Group Health offers its members. For instance: Do insurance coverage, incentives, or both make a difference in either losing extra weight or maintaining a person’s weight over time?

“New Group Health initiatives including the health risk appraisal will let us reach individuals—and their health care providers—directly with health information specific to their own health behaviors and risk factors,” says Arterburn. “That will give us a great potential to engage them in behavior change including obesity prevention and treatment.” The goal is to offer a menu featuring a variety of programs supporting weight management, he says, so individuals can choose which kind of program suits them best at the time.

He is excited about the potential for harnessing Group Health’s triple roles as an insurer, health system, and employer. “Health plans and employers share the burden of the cost of obesity, so it makes sense that Group Health and employers should collaborate and set joint goals to prevent obesity,” he says. “If we both do our part, we can develop a whole new model together.”

Arterburn also plans to continue his multidisciplinary research in obesity and physical activity while fostering collaborative relationships with the VA system, industry partners, state and local leaders, and the University of Washington (UW). For instance, he is part of an interdisciplinary team at the UW called the Exploratory Center for Obesity Research (ECOR). Adam Drewnowski, PhD, a UW professor of epidemiology and medicine who also directs the Center for Public Health Nutrition, directs ECOR. With P20 funding through the NIH Roadmap Initiative, ECOR is fostering research that integrates the biomedical, health care, economic, public health, and policy aspects of the obesity epidemic. The goal is to move scientific discoveries into positive health outcomes.

Through Arterburn, Group Health will play a key role in ECOR’s exploration of health care system strategies for obesity prevention, including insurance coverage and incentives, as well as treatment. Examples of incentives include reducing deductibles, waiving program costs, and cash payments for active participation and weight loss. He will work with CHS Research Associate Evette Ludman, PhD, on the behavioral aspects and with CHS Associate Investigator Paul Fishman, PhD, on costs and cost-effectiveness. With ECOR, they and Grossman are pursuing innovative and effective strategies for obesity prevention, collaborating with basic scientists, public health experts, policy planners, and urban planners.

Hold on. Urban planners?

“The built environment plays a huge role in fostering obesity,” Arterburn explains. Workplaces, in particular, tend to be ‘obesogenic,’ providing disincentives to do any physical activity and incentives to eat continuously. “We need to change the environments where we live and work,” he says, “as well as hearts and minds.” Improvements including safe, well-lighted stairways and encouraging “walking meetings” can help a lot. Walking meetings? “Exercise stimulates thought,” he says.

“We need to act on all fronts at once,” Arterburn adds, explaining this multidisciplinary approach. “Health care providers can’t go it alone. We need to involve employers, schools, public health agencies, community groups, and health care providers, insurers, and systems.” He applauds Group Health’s Cycling for Health promotional program as an example of community involvement. It makes sense, he says, for Group Health to reach out to the community at large, beyond its members, because “we’re one of the main sources of health information for the region.”

Triathlete with a pedometer

Arterburn recently moved from Cincinnati, where he served as assistant professor with the University of Cincinnati and the Cincinnati Veterans Affairs Medical Center. However, he is no stranger to Seattle, having completed a fellowship in health services research and development at the Veterans Affairs Puget Sound Health Care System and earned his master’s degree in public health and community medicine, specializing in health services, at the University of Washington’s School of Public Health and Community Medicine. Earlier, he completed his residency—then serving as chief resident—in internal medicine at the University of Texas Health Science Center at San Antonio.

As an obesity expert, Arterburn feels the need to practice what he preaches. In 2004, he completed his first duathlon (biking and running) and triathlon (swimming, biking, and running), and the multisport bug bit him bad. In 2005 he completed six races, including the Chicago Triathlon in August, and he helped found a new triathlon club in Cincinnati, Cincy Express Multisport. He also wears his pedometer every day and walks and takes the bus to work instead of driving.

As a 1997 graduate of the University of Kentucky School of Medicine and one of the Center’s youngest investigators, David Arterburn indeed moves fast.

Top