Guest Post: Australian GPs Recognise Obesity As A Disease
The following is a guest post from my Australian colleague Dr. Georgia Rigas, who reports on the recent recognition of obesity as a disease by the Royal Australian College of General Practice (RACGP). Last week, the Royal Australian College of General Practice (RACGP) President, Dr Seidel recognised obesity as a disease. The RACGP is the first medical college in Australia to do so. This was exciting news given that we have just observed World Obesity Day a few days ago. According to the Australian Bureau of Statistics1, over 60% of Australian adults are classified as having overweight or obesity, and more than 25% of these have obesity [defined as a Body Mass Index (BMI) ≥30] (ABS2012). Similarly in 2007, around 25% of children aged 2–16 were identified as having overweight or obesity, with 6% classified as having obesity (DoHA 2008). These are alarming statistics. The recent published BEACH data for 2015-162, showed that the proportion of Australian adults aged 45-64yo presenting to GPs has almost doubled in the last 15+ years. Worryingly the numbers are predicted to continue rising, with 70% of Australians predicted to have overweight or obesity by 2025. Embarrassingly, the BEACH data also indicated that <1% of GP consultations centred around obesity management. So obviously what we, as GPs have been doing..,or rather not doing…isn’t working! The RACGP’s General Practice: Health of the Nation 2017 3report found Australian GPs identified obesity and complications from obesity as one of the most significant health problems Australia faces today and will continue to face in coming years as the incidence of obesity continues to rise. But what are we doing about it?…. I think the answer is evident… clearly not enough! Thus, we can only hope that this announcement by the RACGP will have a ripple effect, with other medical colleges in Australia and then the Australian Medical Association following suit. So what does this mean in practical terms? For those individuals with obesity (BMI ≥30) with no “apparent” comorbidities or complications from their excess weight…[though you could argue they will develop (if not already) premature osteoarthritis of the weight bearing joints…..] would be eligible for a chronic care plan [government subsidized access to a limited number of consultations with allied health services] given the chronic and progressive nature of the disease. It also highlights the need for GPs to start screening ALL patients in their practice-young and old; for… Read More »
What Do Health Professionals Need To Know About Obesity?
Achieving and maintaining competencies is an ongoing challenge for all health professionals. But in an area like obesity, where most will have received rather rudimentary training (if any), most health professionals will likely be starting from scratch. So what exactly must you expect of a health professional involved in the care of individuals living with obesity. This is the subject of a white paper on “Provider Competencies for the Prevention and Management of Obesity“, developed with support from the Robert Wood Johnson Foundation. The panel of authors led by Don Bradley (Duke) and William Dietz (George Washington) included representatives from over 20 national (US) professional organisations. The competencies expected cover the following 10 topics: Competencies for Core Obesity Knowledge 1.0 Demonstrate a working knowledge of obesity as a disease 2.0 Demonstrate a working knowledge of the epidemiology of the obesity epidemic 3.0 Describe the disparate burden of obesity and approaches to mitigate it Competencies for Interprofessional Obesity Care 4.0 Describe the benefits of working interprofessionally to address obesity to achieve results that cannot be achieved by a single health professional 5.0 Apply the skills necessary for effective interprofessional collaboration and integration of clinical and community care for obesity Competencies for Patient Interactions Related to Obesity 6.0 Use patient-centered communication when working with individuals with obesity and others 7.0 Employ strategies to minimize bias towards and discrimination against people with obesity, including weight, body habitus, and the causes of obesity 8.0 Implement a range of accommodations and safety measures specific to people with obesity 9.0 Utilize evidence-based care/services for people with obesity or at risk for obesity 10.0 Provide evidence-based care/services for people with obesity comorbidities Some of the topics include further subtopics that are deemed especially relevant. Thus, for e.g., topic 6.o, regarding communication, includes the following sub-competencies: 6.1 Discuss obesity in a non-judgmental manner using person-first language in all communications 6.2 Incorporate the environmental, social, emotional, and cultural context of obesity into conversations with people with obesity 6.3 Use person- and family-centered communication (e.g., using active listening, empathy, autonomy support/shared decision making) to engage the patient and others Similarly, topic 7.0, regarding the issue of weight bias and discrimination, includes the following sub-competencies: 7.1 Describe the ways in which weight bias and stigma impact health and wellbeing 7.2 Recognize and mitigate personal biases 7.3 Recognize and mitigate the weight biases of others This is clearly a forward-thinking outline of competencies that we will… Read More »
1st International Diabetes Expert Conclave (IDEC) 2017
Last week I was an invited plenary speaker at the 1st International Diabetes Expert Conclave (IDEC2017) held in Pune, India. This 3-day event, organised by Drs. Neeta Deshpande (Belgaum), Sanjay Agrawal (Pune) and colleagues, brought together well over 900 physicians from across India for a jam-packed program that covered everything from diabetic food disease and neuropathy to the latest in insulin pumps and devices – all in a uniquely Indian context. I, of course, was there to speak on obesity, which featured prominently in the program. Topics on obesity ranged from the potential role of gut bugs to bariatric surgery. While Dr. Allison Goldfine, former Director of Clinical Research at the Joslin Diabetes Center in Boston spoke on the latest developments in anti-obesity pharmacotherapy (delivering her talk via Skype), I spoke about obesity as a chronic disease and the need to redefine obesity based on actual indicators of health rather than BMI. During my visit in Pune, I also had the opportunity to visit with my friend and colleague Dr. Shashank Shah, whose bariatric surgical center in Pune alone performs about 75 to 100 bariatric operations per month – a remarkable number by any standards. Of course, the overwhelming number of talks were given by Indian faculty (there being only a handful of select invited international faculty at the meeting), and I did come away most impressed by the breadth and depth of knowledge presented by the local speakers. Diabetes care certainly appears to be in good hands although the sheer number of patients with diabetes (estimated at about 70 million, which I assume to be a rather conservative assessment), would provide a challenge to any health care system. On the obesity front, things are a lot less rosy, given that (as everywhere else) obesity has yet to receive the same level of professional attention and expertise afforded to diabetes or other chronic diseases. Thanks again to the organisers for inviting me to this exciting meeting and congratulations on an excellent event that bodes well for the 2nd Conclave planned for 2018. @DrSharma Edmonton, AB
Balancing Benefits And Harms From Redefining Obesity
The final and eight item on the disease definition modification checklist developed by the Guidelines International Network (G-I-N) Preventing Overdiagnosis Working Group published in JAMA Internal Medicine, deals with issue of determining the benefit/harm ratio of the proposed new definition. With terms to redefining obesity as the presence of abnormal or excess body fat that impairs health, I have discussed the potential benefits and harms in previous posts. The question is, whether or not the overall balance comes down on the benefit or harm side of the equation. Here, the authors of the checklist have the following to offer, “Modifying a disease definition should be guided by a balanced assessment of the anticipated benefits and harms, using the best evidence available. The definition should reflect the values and preferences of patients and the wider community and include the impact on resource usage….In general, we recommend that panels consider both an individual and societal approach to assessing the overall benefits and harms of changing disease definitions. We recommend introducing a new disease definition where there is an expected positive balance of harms and benefit for individuals, and in aggregate at the societal level.” In addition, the authors note, “Different definitions may be required for research purposes, for example more stringent standardization, than for clinical purposes where more stringent definitions may deny access to care for patients who would benefit.” Thus, as we have seen, changing disease definitions is not just a matter of opinion but rather, the pros and cons must be considered both at an individual and societal (resource) level. That said, disease definitions are in constant flux as new knowledge and treatments emerge – obesity, should be no exception. Indeed, guidelines would be amiss in not reconsidering the validity of current definitions and exploring potential changes as part of the guidelines process. The published checklist can certainly serve as a guide for this process. @DrSharma Edmonton, AB
Are There Any Harms Of Redefining Obesity?
The seventh item on the disease definition modification checklist developed by the Guidelines International Network (G-I-N) Preventing Overdiagnosis Working Group published in JAMA Internal Medicine, deals with issue of potential harms to patients. Given the obvious benefits of redefining obesity as the presence of abnormal or excess body fat that impairs health outlined in the previous post, it is nevertheless prudent to explore the possibility of unintentional harms. Obviously, expanding the term obesity to include millions of people, who currently fall under the BMI threshold but may well have health impairments attributable to their body fat, may not sit well with these folks. In fact, they may find themselves shocked to learn that they would now be considered to have obesity (more a reflection of the stigma attached to this term, than its non-judgemental medical meaning). Thus, the authors of checklist remind us that, “The potential harms from diagnosis include the physical harms of diagnosis and treatment; psychological effects, such as anxiety; social effects, such as stigma and discrimination; and financial consequences, such as effects on employment….Potential harms also include the misapplication and misinterpretation of the disease definition when taken from a confined research application to more widespread clinical use.” A, perhaps more concerning issue, is the impact that redefining obesity may have on limited resources for obesity management in the healthcare system. “Changes in resource usage can result in harm by reducing access to care for some patients and by diversion and distraction of clinical care. This can happen at both the societal level, with resources taken from areas more important to health, and at the individual level, by distracting individuals from activities more important to their well-being. Modifications of disease definitions can have considerable impacts on costs, including the costs of testing, and the resources needed for treatment and follow-up for those diagnosed using the new criteria. There may also be resources needed for training and implementation regarding the change, and to minimise misdiagnosis. Costs are particularly important in low- and middle-income countries where inappropriate disease definitions can result in considerable diversion of limited health care resources.” These concerns are far from trivial. Not only are current resources for managing obesity in our healthcare systems limited (to non-existant), but one of the main reasons that employers and payers balk at providing access to obesity treatments, is the sheer number of individuals that already qualify for such treatments. Significantly expanding the pool of eligible patients, is therefore. unlikely to be met with much enthusiasm from these stakeholders. Not only would one need to demonstrate… Read More »
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