LOS ANGELES (The New York Times News Service) -- Since he began working out 10 weeks ago at the Max Fitness Academy, 13-year-old Luke Nale has lost 12 pounds, his abs are taking shape and he feels great.

His mother, Debbie, had been concerned about his waistline and cholesterol, which was dangerously high for a child his age, so she signed him up at the gym, one of the few that takes children.

"He doesn't get any exercise at school," she said. "They were teaching him juggling."

She took a proactive approach to her son's health, but many parents, dealing with weight issues of their own, don't. And even doctors are shying away from the topic.

With obesity-related illnesses now costing $28.5 billion annually in lost wages and medical care statewide, two California organizations have stepped in to create "how to" guides to help thousands of doctors emphasize to patients the importance of diet and nutrition to kids and adults alike.

The massive informational "tool kit," available Tuesday, will encourage physicians to conduct body mass index, or BMI, measures on all patients. It will also offer guides on how doctors should discuss weight issues with patients, how to include more information about nutrition inside waiting rooms, and the importance of providing a sturdy scale for those 300 pounds or more, as well as appropriate-size examination gowns.

As a last resort, the guide also recommends how physicians can discuss bariatric surgery, a procedure on the stomach or intestines that limits the volume of food intake.

The California Association of Health Plans and California Medical Association Foundation spent two years compiling the guide after the groups learned that physicians needed to be more direct with patients -- and their waistlines.

"We wanted to put together a united approach to addressing obesity because this is a subject that has a lot of emotion and a lot of stigma associated with it," said Christine Maulhardt, director of obesity prevention for the foundation.

Obesity in Los Angeles County increased from 14 percent of the population in 1997 to 21 percent of the population in 2005, the last year for which data were available, according to the county Department of Public Health.

"California has the image of being a healthy, active state, and for some people that's the case, but overall (the state) lines up with national statistics," Maulhardt said. "We do have a significant portion of residents who are struggling."

Adults and children are defined as overweight or obese by measuring weight and height to calculate the BMI. An adult who has a BMI between 25 and 29.9 is considered overweight, according to the federal Centers for Disease Control and Prevention. A BMI of 30 or higher is considered obese.

Local physicians, dietitians and professional trainers who work specifically with children confronting weight issues say that while the guides are a good idea, state and local governments, schools and especially parents need to confront the issue, too.

"More parents need to be involved in their children's activities," said John Youn, vice president of Drive Kids to Be Fit, a nonprofit program that began through the Max Fitness Academy in suburban Sherman Oaks. "The obesity epidemic has crossed into all social and economic lines."

Pasadena dietitian Wendy Crump said she formed Kids on the Run, an eight-week course that encourages parents to work out and learn nutrition along with their children.

"It is a family-based program because kids can't do it alone," Crump said. "Nutrition education is imperative and it is so powerful. Preventative care is really the optimal solution."

For years, federal health agencies and physicians have been reporting on the health dangers of obesity, but the nation is now seeing how all the problems have converged -- diabetes, depression, heart disease and hypertension all have increased. What troubles many physicians is the presence of adult illnesses in overweight children.

"Part of it is a denial among parents, who are upset with the way the child looks, but they don't want to say anything," said Dr. Norman Lavin, who teaches pediatric endocrinology at UCLA and has a practice at Encino-Tarzana Medical Center in the San Fernando Valley.

Lavin just finished revising his textbook on the subject of pediatric diabetes and for the first time the book includes a chapter on insulin resistance among children, a subject he never thought he would have to tackle.

The tool kit provided by the two state associations also includes suggestions on how to discuss bariatric surgery, which some say should only be approached as a last resort.

"I see that as a quantum leap," Lavin said. "My perspective is let's try to lose weight first. Let's eat right first and exercise."

But Dr. Mark Paya, a bariatric surgeon who works out of Northridge and West Hills hospitals, said more patients are turning to surgical procedures. Education and prevention should come first, Paya said, but when diet and exercise fail, physicians should tell their patients about bariatric surgery.

"We have pretty high referral rates from doctors, but not as high as we want it to be," Paya said. "I think we have to be direct with our patients, and that's what patients like. They should get educated about the procedure, because it saves lives."

More insurance plans also are beginning to cover bariatric surgery, but illnesses related to obesity are placing a strain on insurance companies, too, said Chris Ohman, president of the California Association of Health Plans.

"Obesity puts a $28.5 billion burden on the state of California," he said. "The cost of direct care, workers' comp claims, loss of income -- you put that all together and this is a very costly but preventable disease in California."

Copyright 2008 The New York Times News Service. All rights reserved.