Obesity

Overweight and Obesity

Author: Amanda Lyons

GPs and patients can benefit from a greater range of treatment strategies for overweight and obesity.

Overweight and obesity was declared a ‘global epidemic’ by the World Health Organization in 2000,¹ with its rates throughout the world rising ever since.² In present-day Australia, almost two in three adults are overweight or obese and 25% of children are in the same category.³

‘GPs today are regularly seeing many more people with a body mass index [BMI] in the class two and three obese range [BMI of greater than 35 and 40],’ Prof John Dixon, National Health and Medical Research Council (NHMRC) Senior Research Fellow and Head of Clinical Obesity Research at the Baker Heart and Diabetes Institute, told Good Practice.

The challenging nature of the condition, combined with the difficulty of broaching the subject with patients, has meant that overweight and obesity is not necessarily discussed often during GP consults,⁴ despite its associated health risks.

‘We very frequently see the consequences of being overweight, such as metabolic syndrome, high blood sugar, high cholesterol, and all the flow-on effects from that, such as risk of heart attack, stroke, kidney failure, sleep apnoea, osteoarthritis and joint replacements, and sometimes mental health issues,’ Dr Mel Deery, GP and practice owner with an interest in obesity, told Good Practice.

‘I really feel like, in some ways, treating the obesity epidemic is the holy grail of trying to improve the health of Australians.’

According to Dr Georgia Rigas, GP and Chair of RACGP Specific Interests Obesity Management network, obesity has supplanted most of Australia’s high-profile preventable health risks.

‘Obesity and overweight is the second highest contributor to burden of disease, and this surpasses smoking, which is in third place,’³ she told Good Practice. ‘That often surprises people, because there’s a lot of awareness in society about the adverse effects of smoking, but I don’t think people are as aware of the adverse effects of carrying excess weight.’

Dr Rigas believes this makes it vital for GPs to raise the subject with their patients.

‘As health professionals, we have a duty to discuss with a patient how their weight affects their health and wellbeing. That’s step one,’ she said. ‘Step two is helping the patient actually understand their health condition, while step three is initiating effective evidence-based treatment.

‘An understanding of the chronicity of this health condition and that relapses are to be expected reinforces the need for regular follow-up.

‘As GPs, we are champions in chronic disease management, as we have the infrastructure to support such health conditions. Obesity is no exception.’

 

A complex problem

Some of the current prevalence of obesity can be attributed to social, physical and environmental changes that have taken place over the last three decades, making the condition a complex and challenging one that needs to be addressed at multiple levels.⁵

But although the pervasiveness of the problem can make it seem overwhelming, GPs can actually provide a crucial intervention point for many patients.

‘Over 85% of the population sees the GP at least once a year,’⁴ Lauren Ball, dietitian and NHMRC early career research fellow and senior lecturer at Griffith University in Queensland, told Good Practice. ‘GPs have such a prominent role in helping patients to realise how they can improve their health just by doing simple things.’

Indeed, in the course of her research Ball has found that many patients actually expect their GP to raise the issue of diet and weight.

‘When we speak to patients, they say, “My diet is fine until my GP tells me otherwise”,’ she explained. ‘So it’s almost like they are waiting for their GP to bring it up, and they will address it then.

‘We know that the same is true for their weight. They are really tied in to the same conversation.’

Dr Deery feels that the therapeutic relationship between GPs and patients offers a good entry point for these discussions.

‘We know their history, we know a bit about their personality and what else is going on in their lives,’ Dr Deery said. ‘We have already got a foundation of trust.’

While Dr Rigas has found that many GPs can be wary of bringing up the condition with their patients out of concern they could damage that trust, she believes this can be mitigated by taking the right approach.

‘As long as it’s broached in a sensitive and non-judgemental manner, then I believe the doctor–patient relationship should be preserved. However, it is important to first seek permission from the patient to discuss their weight,’ she said.

 

Change update

Dr Elizabeth Sturgiss, clinical GP and lecturer in general practice at the Australian National University (ANU) in Canberra, is very aware of the challenges facing GPs in treating overweight and obesity.

‘It is a difficult health problem and there have been times when people say, “This is too hard for GPs, it takes too much time”,’ she told Good Practice.

‘But I think with the right structure and support, it is an area in which GPs can make a big difference for their patients.’

Dr Sturgiss began considering the lack of materials available for GPs in this area when some of her own patients wanted her help with overweight and obesity, rather than a referral to other health services. This experience was the catalyst behind the development of the Change Program, a toolkit for a GP-delivered weight management program for adults.

The program was first featured in the January–February 2016 issue of Good Practice halfway into its initial pilot phase. The full pilot – a six-month trial involving 23 patients across four urban practices and one rural practice – has now been completed. The majority of the feedback has been positive, although Dr Sturgiss acknowledged the program may not suit all patients.

‘This program [in itself] is not going to fix the obesity problem,’ she said. ‘But I think we need to have options in programs or approaches for our patients in general practice, so we have something that can suit everyone in every situation – particularly for patients who live in rural areas, where access to allied health services is trickier, or for patients who can’t necessarily afford gap payments.’

The Change Program toolkit provides a patient handbook containing educational material, a fact sheet, and places to record information on nutrition and physical activity. It also includes a GP handbook filled with information about obesity and its management.

Overall, the toolkit is designed to offer a regular structure and supporting information for GPs and patients to work on weight loss together.

‘We wrote the program so that it would take place over two years,’ Dr Sturgiss said.  

‘We want to put the thought in the patient’s head from the beginning that this is long-term behaviour change they’re going to do forever, not a fad that you do for a few weeks and then stop.

‘The program is set up using NHMRC guidelines for frequency of contact with a health professional. It suggests fortnightly visits for the first three months, becoming less frequent after that if the goals are going well and things are on track.’

Dr Deery, who participated in the trial, found the Change Program fitted well into the course of her daily practice.

‘It uses what you already do in general practice in the context of that consultation,’ she said. ‘You don’t need any special equipment.’

However, this did not mean implementing the program was without its challenges.

‘It was a bit of a learning curve for myself and the patients,’ Dr Deery said. ‘I think sometimes they were hoping for some kind of miracle, a bit of a quick fix.

‘But [the Change Program] is basically the science of how to lose weight with a good diet and exercise, and also with motivational coaching throughout it, which I think is really important.

‘Even having that structure, it was still a challenge to keep patients on track, but I think the benefit is the follow-up consultations.

‘Previously, patients might have started a diet and exercise program and fallen off the wagon, but not necessarily had someone there to say, “Let’s try again, let’s set some different goals. How can we make this happen?”

‘Maybe they felt a bit of accountability, as well, which was helpful.’

Although the program didn’t remove the difficulties weight loss, Dr Deery’s patients enjoyed certain positive results.

‘The patients did find it hard,’ she said. ‘But, at the same time, they did have some success. Even a small amount of weight loss has got fantastic health benefits and our patients lost between 5–8 kg over the time, which is really worthwhile weight loss.

‘And hopefully it taught them some strategies they could continue to use.’

While Dr Deery did suggest some areas in which the program could improve, such as providing more specificity in the diet plan, her experience of the pilot was largely positive.

‘I’d love [the Change Program] to be accessible for all GPs in Australia to use with their patients,’ she said. ‘I think it’s a fantastic initiative and if we can make a difference in this space of overweight and obesity in Australia, that would be a really valuable contribution.’

Dr Sturgiss has been pleased with the pilot results, particularly in the way participating GPs reported a confidence boost when dealing with the issue in general practice.

‘Having this one-on-one experience with patients in the pilot meant GPs were more confident to ask other patients in their practice about obesity, and to give more information to patients in their day-to-day work in addition to those they had in the pilot,’ she said. ‘It was great to see that ripple effect.’

Having carried out the pilot, Dr Sturgiss and the ANU research team are looking towards the next trial stage.

‘We’ve developed a protocol to do a clustered randomised trial in general practice,’ she said.

Dr Sturgiss ultimately hopes to expand GPs’ treatment options for overweight and obesity by making the Change Program available throughout Australia.

‘At the moment, overweight and obesity is one of the most mentioned issues when we’re looking at national health priorities,’ she said.

‘We need to start looking at different options, approaches and making sure that, as a profession, we’re on the front foot for having ways to assist our patients.’

 

References

1. World Health Organization. Obesity: Preventing and managing the global epidemic. WHO technical report series; 894. Geneva: WHO, 2000.
2. NCD Risk Factor Collaboration. Trends in adult body-mass index in 200 countries from 1975 to 2014: A pooled analysis of 1698 population-based measurement studies with 19.2 million participants. Lancet 2016;387:1377–96.
3. Australian Institute of Health and Welfare. Overweight and obesity. Canberra, ACT: AIHW. Available at www.aihw.gov.au/overweight-and-obesity [Accessed 24 January 2017].
4. Britt H, Miller GC, Henderson J, et al. General practice activity in Australia 2014–15. Sydney, NSW: Sydney University Press, 2015. General practice series no. 38. Available at http://purl.library.usyd.edu.au/sup/9781743324523 [Accessed 24 January 2017].
5. ­­­Committee of Presidents of Medical Colleges. National Health Summit on Obesity: Report and consensus statement for action. Canberra, ACT: CPMC, 2016.