Obesity needs to be treated in primary care

Given the staggering prevalence of overweight and obesity in most developed countries, there is no other hope than to have general practitioners (and their allied health colleagues) take on the considerable burden of managing obesity in their practices.

In fact, a recent example of a successful weight management program run in primary care just found considerable media attention in local newspapers.

But research shows that most general practitioners (GPs) neither feel confident nor effective in managing excess weight in their patients, and many would rather not bring up the topic of weight management at all.

So what about GP trainees? After all, the next generation of GPs will have little choice but to devote a considerable proportion of their time and practice to dealing with weight-related health issues.

This question was now addressed by Jochemsen-van der Leeuw and colleagues from the University of Amsterdam, in a paper published in Family Practice.

For this study, the researchers conducted focus groups of first- and third-year Dutch GP trainees and their teachers regarding their attitude, willingness, and ability to provide lifestyle interventions for overweight patients.

First-year GP trainees clearly lacked both knowledge and a positive attitude towards addressing weight management.

Perhaps more alarmingly, even third-year trainees, despite being trained in motivational interviewing techniques, also lacked specific knowledge and appeared rather unenthusiastic about providing lifestyle advice.

These attitudes most likely reflect the fact that their trainers were generally despondent about weight management and reported to have rarely observed long-lasting results. In fact, these teachers regularly warn their trainees not to have high hopes.

Tainers and trainees both feared ruining the relationship with their patients by bringing up the issue of weight management and rather preferred having patients enter evidence-based multidisciplinary treatment programmes. They also called for an image change in society to stop the epidemic.

The finding in this study (which I am sure are not just limited to Dutch trainees) are alarming, as they demonstrate that GP trainees are still leaving school without feeling any more competent in treating overweight patients than their trainers.

Under these circumstances, there is indeed little hope that the next generation of GPs will be any better prepared to provide evidence-based weight management advise to their patients than the current generation of GPs.

As the researchers point out, there is an urgent need for a drastic attitude change towards acquiring the competency and efficacy to provide evidence-based obesity treatments both amongst GP trainees and (perhaps even more importantly) amongst their teachers.

Indeed, no GP training program should be allowed to continue graduating doctors, who do not understand even the basics of weight management or do not see this as an important part of their medical practice.

Of course, there are numerous GPs, who are turning their attention to weight management and (as in the example cited above) are beginning to see considerable results in their patients.

If you have had a positive experience with your GP regarding weight management, I’d certainly love to hear about it.

If you are a GP offering weight management advise to your patients, let me hear whether you consider this a worthwhile effort or a waste of your time.

Arya M. Sharma is a Professor of Medicine at the University of Alberta who blogs at Dr. Sharma’s Obesity Notes.

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  • http://twitter.com/moving4wellness Bobby Fernandez

    It has been my opinion for quite some time that GPs need to annoint qualified health and fitness professionals to carry this burden for them.  This ideally would be a sort of prescription for personal training.  We have physical therapists, nutritionists and mental health professionals to deal with pathologies (re-hab) but nobody within the allied health professions to coach the otherwise healthy through lifestyle improvement.  This may be due in part to the lack of quality control in personal training.  If I were king for a day, I would have a special licensure for personal trainers that would qualify them to work as adjucts to the GP for anybody who could use a little help managing their weight. 

  • http://pulse.yahoo.com/_J66QI4KLS6XBZUITDLJRBI5VL4 BBrash

    Follow the money.  1. Patient comes in for hypertension, office visit is completely covered. 2.  Patient comes in for depression: office visit in sometimes partially covered. 3. Patient comes in for obesity: office visit is not covered.  

    Notice any parallels with how “enthusiastically” PCP’s respond when asked to treat the three issues above?

  • http://pulse.yahoo.com/_PDVUUT6POWSYXRB6OHQ73VTVDU Sue

    I once asked for a doctor’s help in helping me with weightloss.  I was told to eat an apple at lunch.  He was totally clueless as to how to get me the help I needed.  It still continues today.  My husband had a heart attack at 42 years old.  He goes to the Doc every three months.  NEVER has he been recommended by the doc to seek nutritional counseling or any other therapy to help him.  I had RNY three years ago, and very happy that I did.  Even then the counseling was mediocre at it’s best.  Something has to change.

  • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

    Two words from the head of the post:

    “considerable burden”

    Why is it that the primary care physicians are always expected to carry these “burdens”?

    Heck, pay for the service, there will be armies of “bariatricians” claiming that primary care physicians are unqualified to tell patients to eat less and exercise more. You need a bariatrics fellowship to say that.

  • Anonymous

     GPs are reasonably discouraged given the dearth of effective evidence-based weight management strategies. Advice to “eat less and exercise more” doesn’t actually qualify, nor does it convey any new news to the patient. I am curious as to what you advocate trainees be taught about weight management. The Edmonton staging system? When to leave well enough alone? I’m somewhat familiar with your blog which is by and large very well informed and sensible, but you don’t specify what is to be done here and so this post blends seamlessly into the futile, bland mass lament about “the obesity epidemic” and how terrible it all is and how doctors and patients just need to try harder. There isn’t an issue with trying so much as there’s an issue with succeeding.

  • Anonymous

    It’s the FOOD!!  Mass produced, genetically modified, pumped up crops (and hooves) that are full of hormones and God-knows what else the industry can dream up to increase profits that is now messing with our metabolism and our HEALTH.  Creating problems that no one can figure out…YET.  There’s your “obesity epidemic” or at least half of it.  

  • http://www.facebook.com/people/Andy-Gillis/1642711617 Andy Gillis

    I don’t think it’s the GP’s responsibility to motivate people to eat healthy and exercise. Recommend, yes! There are so many specialized people in this area that can help. The doctor just needs to refer these patients to a GREAT resource. 

  • Brian Kerley

    Obesity will continue to rise until the medical community catches up with the fact that saturated fat does not give you heart disease. We have fat-a-phobic societies so naturally people are starving all the time and run to easy carbohydrates. The diet-heart/lipid hypotheses, that have lead the assumption that total cholesterol concentration is the go-to biomarker for CVD risk, are the biggest contributor to “Diabesity”. People eat less natural saturated fat, more unnatural omega-6 PUFA from industrial seed oils; Inflammation abound. 

    Nature has it all figured out. Eat happy healthy animals (that eat what they are supposed to eat), vegetables, fruit, and starch that you can pull out of the ground. Get sun and sleep. 

    Slay the lipid/diet-heart hypotheses, live long, and prosper.

    [/rant]  

  • http://twitter.com/sarasteinmd Sara Stein MD

    Nice blog, Arya!
    I wonder if given the correct amount of time, full compensation and the tools to work with obesity, and an integrated team…wouldn’t primary care drs begin to see this as rewarding, rather than impossible? I’m not sure that PCP’s know where to start, other than “Eat Less, Move More”, mostly doomed for failure, or “have you considered bariatric surgery”.

    Bariatric Medicine is a wonderful and needed subspecialty, but most patients will never see specialists, and specialists ought to be reserved for the most complex cases. That said, currently PCP’s have few to none of the bariatricians tools for weight management. 

    In addition, no one provider can do this all – bariatric treatment requires an integrated team to address medical, nutrition, movement, psychology, social and family. They grew heart surgery treatment into wrap around services, same with cancer treatment…hopefully obesity treatment is next.

    Maybe the beginning is training, insurance reimbursement (now that obesity has attained “disease” status), appropriate designated appointment time, and multidisciplinary teams.

    It’s an incredibly rewarding group of patients to work with, and it only takes one 100-lb loser to get hooked. If only our systems provided the help needed to the providers. Someday!!

    Best, Sara

  • http://www.facebook.com/people/RIchard-Feinman/100002248386290 RIchard Feinman

    My GP does not normally intervene and sends patients to a dietitian.  He was impressed that I lost thirty pounds and had still kept it off for 3 or 4 years.  He is in the University Hospital at Downstate where I teach biochemisry and metabolism emphasizing the importance of carbohydrate restriction and the failure of low fat.  Although, strictly speaking, we don’t recommend anything for weight loss — we do suggest that low-carbohydrate diets are the “default” diet )the one to try first) for diabetes and metabolic syndrome. In any case, my GP came to a low-carbohydrate conference which he described as an “eye-opener” although he still felt that he did not have the expertise to recommend dietary interventions.  My general experience at the medical center is that physicians are open-minded but in nutrition, you have to not only study the subject but you have to be prepared to go against recommendations of virtually every government or health agency and you have to do the work yourself.  If you send the patient to a nutritionist, they will do the work although it will be following the party line.  Unfortunately, the nutritional boards of these agencies are populated with MDs who have had no more training than my GP but are immodest and prepared to insist on their opinions and may be distinguished by quest for political power.  If we want to increase the training of future GPs, who will train them? 

  • Anonymous

    Addiction to sugar, fat and salt is the probem and obesity/overeating or just unhealthy eating is the biggest RISK factor for chronic preventive disease.  Fruits and vegetables are the basic medicine – then the rest of the healthy diet varies a bit according to who you listen to BUT it sure doesn’t include a lot of animal products or sugar or much salt.  I’m neither an MD or a dietician and I got it.  Ask your obese/patients what they need to do – they know. But how do docs and other health professionals change an environment that is flashing neon signs – eat big steaks, fries, ice cream. fried foods – its the American way -  then ads – take my anti acid pills and you will be OK to overeat another day.  Try telling Big Food or Big Pharma they are the biggest part of the problem HA!!!  I think it is a conspiracy. 

    How can anyone not know.  It used to be a question of didn’t know, didn’t do -  but not anymore.  Except kids. 

    It must come to changing our eating culture as well as healthcare.  

     

     

  • Anonymous

    A recent report in Science ( Aug 2011) indicates Europeans are getting taller by 1 cm per decade.  Height is genetic.  To be getting taller suggests the influence of growth-like hormone – probably in the environment – food and plastics, etc.  So people, including babies, are getting taller and fatter. It is difficult for a doc in the context of office visits to address this.

  • Anonymous

    David Allison, U Alabama biostatistician, reported in Nov 2010 on the fact that 8 species of animals have all gotten fatter – including alley rats, pet dogs and cats, lab chimps.  The chances of this occurring by chance is 1 in 8 million according to the biostatistician.  The rats are not getting driven to school or missing out on p.e.  It seems it’s environment is a contributng factor.