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Primary Care Needs to Restructure Its Approach to Obesity



As report after report expresses concern about the rising prevalence and health impacts of obesity, it is becoming increasingly clear that business as usual is not going to work in addressing this epidemic.

Regular readers will recall the recent WHO/OECD analysis, which concluded that it will take decades for prevention efforts to show any sign of reversing the epidemic. This means that millions of North Americans will need obesity treatments, whether behavioural, pharmacological, or surgical.

Given the sheer numbers, much of this treatment will need to be delivered in primary care – and herein lies the problem. Can primary care deliver what is needed?

In an editorial published in this week’s issue of the Archives of Internal Medicine, my friend and colleague Robert Kushner (past President of The Obesity Society and co-author of our paper on the Edmonton Obesity Staging System) questions whether primary care is up to this challenge.

Despite all recommendations and guidelines, obesity is underrecognized and undertreated in US primary care. The US National Ambulatory Medical Care Survey (NAMCS) estimated that obesity-related counseling occurred in only around 25% of visits and the rates are declining.

According to Kushner, “The reasons for the gap are complex owing to multiple physician, patient, and medical system factors. Barriers include a lack of reimbursement, limited time during office visits, lack of training in counseling, competing demands, low confidence in the ability to treat and change patient behaviors, limited resources, the perception that patients are not motivated, and a paucity of proven and effective interventions to treat obesity.

Obesity treatment is often perceived by physicians as a daunting or even futile task. In addition, stigmatization of the patient may pose a major barrier.

As Kushner sees it, at least two changes are needed to engage PC physicians in obesity care: systematic reorganization of office-based processes and physician training in obesity care.

Not only must obesity be addressed in the same manner as other chronic diseases, but PC physicians need to acquire skills to work with multidisciplinary care teams (nurse practitioners, registered dietitians, health psychologists, and exercise specialists), as well as obtain a reasonable knowledge of the principles of diet, physical activity, and obesity care.

In summary, nothing that regular readers of these pages will not have heard from me before.

Although the article focusses on the US, there is not the slightest indication that the situation in Canada is any different.

As I have said before, obesity management belongs in primary care – it needs to be managed with the same enthusiasm, resources and perseverance as other chronic diseases

Not treating obesity when obesity is the problem, is simply palliative care.

AMS
Edmonton, Alberta

10 Comments

  1. Obesity management belongs in the hands of the obese. They don’t need doctors to be successful.

    -Steve

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  2. Hello Arya! Your question “Can primary care deliver what is needed?” is fundamental to identify and work on the aspects that are crucial to obtain favourable results in this approach for obesity, we must start that way, but I would also add to the participation of the multidisciplinary teams an every time increasing involvement of the sociocultural networks that surround patients with the goals of health of patients, because very often I get the impression that health teams (even in an ideal multidisciplinary scenario) have limited capability of making people eat healthy and become or remain physically active in this society. I don’t yet imagine how to develop this society-health care connections but I think that would also be needed.
    Have a nice week!

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  3. While obesity could be such a complcated and paralysing (both emontionally and physically)disesase condition, I have a hradtime to understand Dr Parker’s comment on how “Obesity mangement belongs in the hands of the obese”
    There is a need to be aware of the complications and conseling as to what he problem is and how over come it, there is a need to be motiveated to seek therapeutic attanetion and there is a need for all the support they can get form family, health care professional and the society and yet how many are eventually successfully managed?
    I totally agree that primary care is the way to go and begin with….that should be the first stop to seek medical attention and yes we need to educate young doctorss on raising medical problem such as obesity (or as I say modern life diseases), increase awareness in the society (schools, universioties, etc.) and motivate people with obesity to seek treatment. Where would be a better place to begin with than PC physicains?

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  4. If a GP were to tackle the obese patients, he would need to measure it more effectively than BMI, develop and control the type of treatment, oversee the quality and outcome of the treatment plan and measure goals on a periodic basis appropriate for each patient.

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  5. Hi Arya: It is gratifying to hear your recommendations concerning the role of Primary Care in the management of OBESITY. It has been frustrating for those of us that have recommended, for over a decade, training of our Family Physicians in the managment of the devastating epidemic of obesity in North America which, in its chronicity, associated diseases and overall impact on the continent’s health care, vastly overshadows the H1N1 and HIV infectious epidemics.

    Our critical first step as medical care providers is to determine what of our current therapies is most effective (although none is the complete answer) and begin instruction, at the Medical School level within the year.

    I would propose that those who are currently providing evidenced based weight management care at the Medical level, meet under your leadership as soon as possible. The conference could deal with recent updates regarding obesity research and presentations of the most effective techniques which could be adjudicated and chosen on the basis of merit in the area of effectiveness and practicality for use by Family Physicians. During clinical years medical students and interested post graduate physicians could also choose to be mentored in appropriate treatment clinics. I believe such an effort is now necessary and more than timely.

    I have one modification to suggest regarding your last statement:
    “Not treating obesity, when obesity is the problem, (is simply palliative care”) is medically irresponsible!

    Regards Doug

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  6. I agree that for obesity management to have a sustained effective impact, primary care physicians will have to take the lead in providing the long-term continuity, trust and rapport required to treat these patients. After practicing primary care for 5 years, I finally realized that I had to do something to try and help my obese and overweight patients. Continuing to admonish them to “exercise more and eat less” while prescribing more medication for their multiple obesity related comorbid diseases was not working. For the last two years I have incorporated formal obesity management with both my own internal medicine patients as well as consult patients from the community. It has not been an easy task, but in my opinion, we have helped many patients in trying to control this chronic disease. The core of most of the treatments if rendered, is based on either meal replacements or medications in coordination with collaborative behavioral counseling, RDs, exercise physiologists, and bariatric-surgical referrals. To do this in a non-academic setting is extremely difficult without having both highly motivated patients and a very willing administrative team. I agree with Dr Kushner’s recomendations that in order for the future primary care based system to effectively start addressing the obesity problem, we need a systematic reorganization of office based processes and functions and physician training in obesity care. Just how to actually implement this is the central challenge. Personally speaking, if it were not for evidenced-based insightful physicians such as Dr Sharma, I too, would feel that obesity treatment by physicians is a daunting and futile task. Thank-you.

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  7. The above comments are reassuring that there is a understanding that most 900 cal meal plans result in long term weight regain, if the intervention is not followed by an intense intervention to keep the weight off. That intervention is surgery. I will only agree with a VLCD program that has surgery as an endpoint. That being said, there are many, many people with BMI greater than 40 who cannot go to surgery, and the results of the Look Ahead trial that used 2 meal replacements + 1 protein bar for the frist 3 months, and then 1 meal replacement and 1 protein bar after that, is reassuring, that these patients may be able to ameliorate disease and keep weight off in the long term. I agree with the use of meal replacements, for those not going to surgery, if this (Look Ahead) type of approach is used. We are using this approach in our diabetic patients, at the Wharton Medical Clinic and will publish results on this within the next year or so, and with oalmost 1500 diabetic patients at our clinic, we have quite a bit of data to present.

    Sean Wharton, MD

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  8. weight management should belong to the hand of primary care and specialist / diabetology, internal, cardiology, enodcirnology / as well.

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  9. It was great to see the comments about the need for healthcare professionals to learn about interprofessional practice. This requires an understanding and appreciation for the contributions of disciplines, including medicine, to the treatment and management of obesity. More universities are requiring students in healthcare professional programs to take courses that focus on interprofessional collaborations for patient care. I am currently facilitating an on-line interprofessional education module. In this module, students from medicine, nursing, occupational therapy and physiotherapy programs discuss their individual and shared roles with a patient who has chronic health conditions including obesity. I am hoping that the students who participate in this module will have a better appreciation for the complex nature of obesity and the need for interprofessional care. We have links to the Canadian Obesity Network and the preceptorship program and encourage students to take more courses that focus on obesity. Would like to know what other universities are doing to promote interprofessional collaborations.
    Mary Forhan OT

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