Time for a rethink on dealing with obesity?

The World Health Organization forecasts 89% of Irish men will be overweight by 2030, and almost half will be obese, with rates of obesity for women increasing from 23-57%¹ over 15 years. Obesity is a determinant of frequent attendance in general practice.² Behaviourally based treatments are considered safe and effective for weight loss and maintenance.³

There are unspoken assumptions that GPs are ‘well placed’ and patients identified will engage with the process, particularly given the level of public health messaging on this issue in most societies. GPs view their own efforts at intervention as largely ineffective.⁴ This study explores the present acceptability and uptake of standard interventions in general practice.

Methods

BMI screening was offered to 100 patients (18-65) as they serially presented to a single training general practice (Abbey House Medical Centre, Navan in 2016). Overweight patients were identified by screening for height and weight and calculating BMI. They were categorised as overweight as per WHO BMI classification. 

They were offered treatment and assigned alternatively to standard or intervention treatment groups. The standard treatment group was given advice sheets from www.patient.co.uk, and offered review at four months. The active treatment group involved standard treatment, plus being reviewed at monthly intervals for four months (offered review), being given a food diary, a logbook, weight loss programme advice, (recommended app: “my fitness pal”), weight loss targets, and motivational interviewing. 

The Active Treatment Model was taken from ‘Brief Interventions in Weight Management’, in keeping with overall national health policy.⁷ The methodology initially was subjected to pilot (n = 10) for clarity and acceptability.

Results

At the outset, 20 of 100 individuals declined screening. Of the remaining 80, 35 were identified and coded for overweight/obesity. Of those screened (n = 80), 35 patients were overweight (n = 17) or obese (n = 18). Ten of these patients in turn declined treatment. 

The remaining 25 patients were randomly assigned to standard or active treatment for a four month period. In the active treatment group (n = 12): one person opted out by phone, another presented for review after one month without their logbook (their weight had reduced from 86kg to 84kg), and they subsequently failed to follow-up. 

All others enrolled did not attend for follow- up (n = 10). Among those in the standard treatment group (n = 13), only two patients returned. In both cases, BMI was unchanged. All remaining did not attend for follow up (n = 11). In total, the number who formally opted out in the course of the study was one.

Ethical approval was obtained from the TCD HSE GP Training Scheme Ethics Committee. All patient’s provided informed written consent for the intervention wing of the study. Verbal consent was obtained for weight and height measurements and was noted in the electronic medical record (EMR). A patient information sheet was provided to all enrolled participants. 

Discussion

The increasing prevalence of obesity has been consistently highlighted as a key public health issue (44% of those screened are overweight or obese). In this study, general practice screening was declined by 20%, but of the 80% screened, 35 previously undiagnosed patients were identified as overweight and coded in the EMR. Therefore, the identification of an important treatable condition, reliably and easily diagnosed, was not acceptable to a proportion of patients in the study. 

Of those who were screened and identified as being overweight or obese, engagement with interventions was poor or non-existent. 

In a complex adaptive care system there are multiple factors at play influencing patient engagement with a health issue such as obesity. The origins of obesity itself are complex and include a variety of genetic, socio-economic and environmental factors. The players include families, schools, retailers, industry, government agencies, the media, healthcare providers, city planners, architects, employers, and many more.⁹ The dopamine-mediated reward system’s reaction to eating certain sugars has led many to compare it to an addictive substance. In summary, the obesity epidemic is complex.

Complex adaptive systems can be summed up in two words: information and incentives.⁸ Any intervention, such as the ones offered in this study, will be less likely to be successful without multi-level information for service users and incentives for patients and other players in the system. 

This study, at face value, looks at the acceptability of screening and interventions to patients. The information provided to patients was in the form of written information and a five-minute explanation at the end of a consultation.⁷ The impact of this can only be measured in outcomes in a complex adaptive system and in this context appears to be of little value.³

The incentives provided to patients were a reduction in weight and improvement of overall health and prevention of associated diseases. There was a lack of a current robust public health campaign on overweight, such as those for smoking or road traffic accidents. 

There was no incentive for the GP providing the service other than improving the health of their patient and they had no specialist training in the management of established obesity. 

Arguably, without financial incentives for patients (ie. sugar taxes, tax breaks for healthy foods) and the powerful dissemination of information (ie. television and internet advertising, health warnings on packaging), interventions such as the one in this study will continue to fail. The template of recent public health campaigns targeting smoking is readily available but not being implemented by policy makers for obesity. 

A complex adaptive system

There was less than expected patient engagement with screening and treatments for obesity in general practice. As outlined in the discussion, a different social and environmental context may have improved the outcome of this intervention. In the absence of the widespread dissemination of accessible information on obesity for patients and without the appropriate incentives for patients and other players in the system, studies such as this will have less than optimal outcomes. 

General practice is well equipped to identify and quantify the obesity problem but, based on this evidence, is not best placed to manage it alone. A more co-ordinated approach considering all the players in this complex adaptive system should be considered. 

References

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3. Leblanc ES, O’Connor E, Whitlock EP, Patnode CD, Kapka T. Effectiveness of primary care-relevant treatments for obesity in adults: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2011;155(7):434-47
4. Leverence RR, Williams RL, Sussman A, Crabtree BF, Clinicians Rios N. Obesity counseling and guidelines in primary care: a qualitative study. Am J Prev Med 2007;32(4):334-9 
5. O’Brien SH, Holubkov R, Reis EC. Identification, evaluation, and management of obesity in an academic primary care center. Pediatrics. 2004;114(2):e154-9
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7. Cavill, N, Hillsdon M, Anstiss T. Brief interventions for weight management. Oxford: National Obesity Observatory, 2011 
8. Rouse WB; Health Care as a Complex Adaptive System: Implications for Design and Management, 2008
9. Hammond RA, Complex Systems Modelling for Obesity Research 2009. Prev Chronic Dis. 2009 Jul;6(3):A97. Epub 2009 Jun 15