Obesity Management Belongs In Primary Care
No matter if and when obesity prevention efforts bear fruit, there are currently well over 6,000,000 Canadian adults and children, who could benefit from obesity management today. Even, if one were to limit more intense obesity management (such as behavioral, pharmacological and/or surgical treatments) to those with more severe obesity (Edmonton Obesity Staging System 2+), this would still overwhelm the capacity of existing tertiary care systems. Thus, as William Dietz and colleagues point out in their recent article in the 2015 Lancet Obesity Series, even the majority of severe (or complicated) obesity will still need to be managed in primary care. “Care for adults with severe obesity has generally been delivered in tertiary-care centres. Although such programmes are efficacious, they are poorly suited to address the number of patients with severe obesity. Alternative approaches for the management of adults with severe obesity include primary-care settings or community settings to deliver care.” However, “Transition from efficacy to effectiveness will require substantial and challenging changes in how primary care is delivered. Practices often lack the organisational structure, such as patient registries and methods for systematic tracking to assess clinical interventions, care teams to manage patients with chronic illnesses, or health information systems that support the use of evidence-based practices at the point-of-care to provide longitudinal care for chronic illnesses.” Where they exist, these structures are already at capacity dealing with other chronic diseases including diabetes, hypertension, COPD and other lifelong disorders. Even if many of these problems are directly related to excess weight (or would at least substantially improve with weight loss), most primary care practitioners have yet to take on the challenge of managing obesity (not just the obese patient). Surely enthusiasm for obesity management will increase in primary care settings as more effective obesity treatments become available – making these available to those who stand to benefit, needs to be a key priority of health care system planners and payers. The fact that many payers chose not to cover obesity treatments by delegating this to the category of “lifestyle”, shows that they have yet to take obesity seriously as a chronic disease in its own right. It may also demonstrates their biases and discrimination of people living obesity – after all the same payers have no problem shelling out billions of dollars to treat other “lifestyle” disorders like strokes, heart attacks, type 2 diabetes or COPD. This is where health policies can… Read More »
Early Bird Registration For Canadian Obesity Summit Ends March 3rd
For all my Canadian readers (and any international readers planning to attend), here just a quick reminder that the deadline for early bird discount registration for the upcoming 4th Canadian Obesity Summit in Toronto, April 28 – May 2, ends March 3rd. To anyone who has been at a previous Canadian Summit, attending is certainly a “no-brainer” – for anyone, who hasn’t been, check out these workshops that are only part of the 5-day scientific program – there are also countless plenary sessions and poster presentations – check out the full program here. Workshops: Public Engagement Workshop (By Invitation Only) Pre-Summit Prep Course – Overview of Obesity Management ($50) Achieving Patient‐Centeredness in Obesity Management within Primary Care Settings Obesity in young people with physical disabilities CON-SNP Leadership Workshop: Strengthening CON-SNP from the ground up (Invitation only) Exploring the Interactions Between Physical Well-Being and Obesity Healthy Food Retail: Local public‐private partnerships to improve availability of healthy food in retail settings How Can I Prepare My Patient for Bariatric Surgery? Practical tips from orientation to operating room Intergenerational Determinants of Obesity: From programming to parenting Neighbourhood Walkability and its Relationship with Walking: Does measurement matter? The EPODE Canadian Obesity Forum: Game Changer Achieving and Maintaining Healthy Weight with Every Step Adolescent Bariatric Surgery – Now or Later? Teen and provider perspectives Preventive Care 2020: A workshop to design the ideal experience to engage patients with obesity in preventive healthcare Promoting Healthy Maternal Weights in Pregnancy and Postpartum Rewriting the Script on Weight Management: Interprofessional workshop SciCom-muniCON: Science Communication-Sharing and exchanging knowledge from a variety of vantage points The Canadian Task Force on Preventive Health Care’s guidelines on obesity prevention and management in adults and children in primary care Paediatric Obesity Treatment Workshop (Invitation only) Balanced View: Addressing weight bias and stigma in healthcare Drugs, Drinking and Disordered Eating: Managing challenging cases in bariatric surgery From Mindless to Mindful Waiting: Tools to help the bariatric patient succeed Getting Down to Basics in Designing Effective Programs to Promote Health and Weight Loss Improving Body Image in Our Patients: A key component of weight management Meal Replacements in Obesity Management: A psychosocial and behavioural intervention and/or weight loss tool Type 2 Diabetes in Children and Adolescents: A translational view Weight Bias: What do we know and where can we go from here? Energy Balance in the Weight- Reduced Obese Individual: A biological reality that favours… Read More »
Health Professionals’ Weight Bias Does Not Help
Yesterday, I discussed the dire need for health professional education in obesity, a topic of keen interest to Bill Dietz and colleagues in their paper in the 2015 Lancet series on obesity. This lack of professional training in obesity is not helped by the well known and widespread weight-bias and discrimination that is rampant amongst most health providers, administrators and policy makers (not to mention the general public). Thus, “Weight bias by preclinical and medical students includes attitudes that patients with obesity are lazy, non-compliant with treatment, less responsive to counselling, responsible for their condition, have no willpower, and deserve to be targets of derogatory humour, even in the clinical-care environment. These biases can also lead to views that obesity treatment is futile and feelings of discomfort, which students report as a barrier to discussing weight with patients, both of which are likely to impair care.” These attitudes have real consequences for people living with obesity, “Providers spend less time in appointments, provide less education about health, and are more reluctant to do some screening tests in patients with obesity. Furthermore, physicians report less respect for their patients with obesity, perceive them as less adherent to medications, express less desire to help their patients, and report that treating obesity is more annoying and a greater waste of their time than is the treatment of their thinner patients” It should come as no surprise that patients who experience these attitudes are less likely to seek medical care, even when needed, “Among the heaviest women, 68% reported delaying use of health-care services because of their weight, due to previous experiences of disrespectful treatment from health-care providers, embarrassment about being weighed, and medical equipment that was too small for their body size.” This not only directly harms patients but also substantially adds to the cost of the disease as the delay in diagnosis and treatment for obesity-related comorbidities can impair the quality of care for individuals with obesity. However, these challenges are not insurmountable, “Information about obesity that indicates contributing factors beyond personal control (eg, biological and genetic contributors) as well as the difficulties in obtaining clinically significant and sustainable weight loss, has been shown to reduce negative bias and stereotypes among preclinical and medical students and improve self efficacy for counselling patients with obesity.” This is why the Canadian Obesity Network has made addressing weight bias and discrimination its #1 priority in all… Read More »
Health Professionals Are Poorly Prepared To Address Obesity
“…health professionals are poorly prepared to address obesity. In addition to biases and unfounded assumptions about patients with obesity, absence of training in behaviour-change strategies and scarce experience working within interprofessional teams impairs care of patients with obesity.“ This quote, taken from the paper by William Dietz and colleagues included in the 2015 Lancet series on obesity, pretty sums up the dire state of affairs when it comes to health professionals’ ability to help people living with obesity. While governments around the world continue to dither on prevention measures, and even if these were implemented, would take decades to substantially reduce global obesity rates (a halting in progression would already be widely considered a major success), health care systems the world around are challenged with an enormous clinical burden that will require innovative treatment and care-delivery strategies are needed. Well, not all that innovative – after all, the very same health care systems are well versed with providing ample care for scores of other chronic diseases – obesity is just not one of them. As Dietz points out, “Existing shortcomings of current health-service delivery include poor teamwork, a mismatch of competencies to the needs of patients and populations, episodic rather than continuous care, and hyperspecialisation.” In fact we don’t even know if health professionals are actually being trained for this at all, “A scarcity of information exists for undergraduate medical education in obesity, and even less information is available for nursing and allied health professional students.” Despite various high-sounding recommendations, “Overall, the level of implementation of health professional education in obesity at all levels appears inadequate in several countries….The Royal Australian College of General Practitioners is the only specialist training college to include obesity in the prescribed curriculum.” In Canada we are still licensing family physicians without any requirement to have spend even a single day in a bariatric centre. The recently released Canadian Obesity Practice Guidelines, endorsed by the Canadian College of Family Physicians, provide virtually no guidance to family doctors apart from the rather strong recommendation (based on virtually non-existent evidence) to record BMIs on all patients. According to Dietz, “Commonly identified areas for additional training in the care of adults with obesity include motivational interviewing, the comanagement of bariatric surgery patients, and nutrition and exercise counselling.” Clearly, the emerging role of pharmacotherapy will add a further dimension to the need for health professional education. None of this… Read More »
The Lancet’s 2015 Take On Obesity
In 2011, The Lancet dedicated a special issue to the topic of obesity – the general gist being that obesity is a world wide problem which will not be reversed without government leadership and will require a systems approach across multiple sectors. The Lancet also noted that current assumptions about the speed and sustainability of weight loss are wrong. This week, The Lancet again dedicates itself to this topic with ten articles that explore both the prevention and management of obesity. According to Christina Roberto, Assistant Professor of Social and Behavioural Sciences and Nutrition at the Harvard T H Chan School of Public Health and a key figure behind this new Lancet Series, “There has been limited and patchy progress on tackling obesity globally”. Or, as Sabine Kleinert and Richard Horton, note in their accompanying commentary, “While some developed countries have seen an apparent slowing of the rise in obesity prevalence since 2006, no country has reported significant decreases for three decades.” As Kleinert and Horton correctly point out, a huge part of this lack of progress may well be attributable to the increasingly polarised false and unhelpful dichotomies that divide both the experts and the public debate, thereby offering policy makers a perfect excuse for inaction. These dichotomies include: individual blame versus an obesogenic society; obesity as a disease versus sequelae of unrestrained gluttony; obesity as a disability versus the new normal; lack of physical activity as a cause versus overconsumption of unhealthy food and beverages; prevention versus treatment; overnutrition versus undernutrition. I have yet read to read all the articles in this series and will likely be discussing what I find in the coming posts but from what I can tell based on a first glance at the summaries, there appears to be much rehashing of appeals to governments to better control and police the food environments with some acknowledgement that healthcare systems may need to step up to the plate and do their job of providing treatments to people who already have the problem. As much as I commend the authors and The Lancet for this monumental effort, I would be surprised if this new call to action delivers results that are any more compelling that those that followed the 2011 series. I can only hope I am wrong. @DrSharma Edmonton, AB
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