The past two days, I’ve been at a young investigator’s meeting convened by the Canadian Institutes of Health Research Institute for Nutrition, Metabolism and Diabetes, in Kelowna, BC.
This annual event brings together promising and emerging young investigators working in the fields of metabolic, renal and digestive disease from across Canada.
The talks by experienced faculty are given on topics ranging from grant writing, finding a good mentor and building partnerships (my topic), to the importance of not forgetting about work-life balance.
There is no doubt that every year, the research environment for funding becomes yet more competitive. Thus, it is always refreshing to see the enthusiasm, passion and enthusiasm with which young researchers approach the many research questions that desperately need answers.
Finding better ways to prevent and treat obesity are certainly among the top issues on the list, and it was therefore not surprising to see several of the research projects presented by the young attendees focusing on various aspects of obesity.
I found attending this event particularly rewarding as this was a reunion with several past “bootcampers” (attendees of the Canadian Obesity Network’s annual Obesity Research Summer School), who, I am happy to say, have progressed nicely into junior faculty and new investigator positions.
Congratulations to the organisers and all who had the privilege of attending.
Obesity, like most other chronic diseases, requires interdisciplinary approaches that involves a wide range of clinicians from different disciplines (e.g. physician, nurse, psychologist, dietitian, exercise physiologist, social worker, physiotherapist, occupational therapist, etc.).
But exactly how to get these teams to function efficiently and deliver timely and ongoing obesity management remains largely understudied.
In a paper by Jodi Asselin and colleagues, published in Clinical Obesity, we explore the challenges faced by members of multidisciplinary teams working in the setting of a large primary care network.
Participants (n = 29) included in this analysis are healthcare providers supporting chronic disease management in 12 family practice clinics randomized to the intervention arm of the 5As Team trial including mental healthcare workers (n = 7), registered dietitians (n = 7), registered nurses or nurse practitioners (n = 15). Participants were part of a 6-month intervention consisting of 12 biweekly learning sessions aimed at increasing provider knowledge and confidence in addressing patient weight management.
Qualitative methods included interviews, structured field notes and logs.
Four common themes of importance in the ability of healthcare providers to address weight with patients within an interdisciplinary care team emerged, (i) Availability; (ii) Referrals; (iii) Role perception and (iv) Messaging.
Availability (i) refers to the ability of two or more people to meet and communicate as needed within a reasonable amount of time. This included the interdisciplinary team members knowing and meeting each other, being able to consistently communicate during the work-day, or deliberately asynchronously, and having work schedules that allowed collaboration.
Availability was often affected by scheduling that limited face-to-face time between providers and subsequently limited the potential for collaboration or discussion. Another issue was lack of in-clinic time to speak to providers who were physically present but otherwise unavailable.
Referrals (ii) points to the need for weight management referrals to take place, for those referrals to be appropriate to provider ability and for the patient to be knowledgeable about, or in agreement with the reason for referral. Many practitioners felt they were not receiving the weight management referrals they could, or that the referrals often left the patient and provider unclear as to where to begin the conversation.
Role perception (iii) concerns the way a provider’s role is understood by other interdisciplinary team members. Issues pertaining to role perception were fairly consistent and strongly linked to concerns with referrals. Common examples included concern that they were not receiving the type of referrals they could, that other providers did not understand their role in weight management, or that they as providers did not understand the role of others.
Messaging (iv) refers to the overall approach to weight management that providers within the same clinic were using, as well as the key information being shared between providers and patients. Inconsistent messaging among providers within clinics, as well as with specialists seen by the patient, was a common concern raised during interviews. In such cases there was feeling that advice was not patient-centred, that efforts had not been taken to consider patient history and that as a consequence, the patient might suffer a setback, reduced interest, or reduced personal confidence. In these cases the message a patient had received from another provider was counter to the message or approach the interviewee was giving.
However, we find that what was key to our participants was not that these issues be uniformly agreed upon by all team members, but rather that communication and clinic relationships support their continued negotiation.
Our study shows that firm clinic relationships and deliberate communication strategies are the foundation of interdisciplinary care in weight management.
Furthermore, there is a clear need for shared messaging concerning obesity and its treatment between members of interdisciplinary teams.
From the project it is evident that broad training in the various contributors to obesity enables providers to not only see their own role in treatment, but to better understand the role of others and therefore begin addressing problems in referrals, messaging and role perception.
Although bariatric surgery is by far the most effective treatment for severe obesity, most health professionals will have learnt little about it during their training. For those who did, much of what they learnt is probably obsolete, given the remarkable advances both in surgical technique as well as patient management.
Given that the family doctor may often be the key person to suggest or counsel patients about the pros and cons of bariatric surgery, refer appropriate patients for surgery and manage them long-term in the years following surgery, it is essential that they have a sound understanding of the indications, risk and benefits of surgery.
Now, a survey of Ontario family docs, published in Obesity Surgery by Mark Auspitz and colleagues from the University of Toronto, reveals important knowledge gaps and misconceptions about bariatric surgery.
The 28-item questionnaire, sent to 1328 physicians in Ontario resulted in 165 responses.
Overall experience was limited: around 70% of responding family physicians had less than five surgical patients in their practice, almost 10% had none.
The vast majority of responders (70 %) stated that they at best referred about 5 % of their patients with severe obesity for surgery.
Not surprisingly, compared to physicians who had previously referred patients for surgery, physicians who had never referred a patient for surgery were less likely to discuss bariatric surgery with their patients (30 vs. 79 %), less likely to feel comfortable explaining procedure options (6 vs. 34 %) or providing postoperative care (27 vs. 64 %).
Virtually all (92%) of family physicians stated that they would like to receive more education about bariatric surgery.
To the question as to whether or not they would consider referring a family member for surgery, only 56% of docs who had never referred a patient would consider it, compared to 85% of physicians with previous referrals.
As a side note, only 30% of responders felt that they had the appropriate equipment and resources to manage patients with obesity.
Unless one assumes that the docs who responded to this survey are somehow very different from the docs who didn’t, one must conclude that there are indeed considerable knowledge gaps about bariatric surgery among family docs in Ontario (and I have no reason to believe that this situation would be much better anywhere else in Canada).
On a positive note, it appears that the vast majority of docs are keenly aware of this deficit and would appreciate more education on bariatric surgery.
How much does your doctor know about it?
This is even more true for children with physical disabilities, who face even greater challenges when it comes to preventing or managing excessive weight gain. Unfortunately, not much is known about the extent of this problem or possible solutions.
Now a group of Canadian experts in paediatrics and rehabilitation have put out a Call to Action, published in Childhood Obesity, for a research agenda that focuses on this important sub-group of kids.
The call is the result of a Canadian multistakeholder workshop on the topic of obesity and health in children with physical disabilities that was held in October 2014.
The participants in the workshop included researchers, clinicians, parents, former clients with disabilities, community partners, and decision makers.
Given the paucity of research in this area, it is not surprising that the participants identified over 70 specific knowledge gaps that fell into 6 themes: (1) early, sustained engagement of families; (2) rethinking determinants of obesity and health; (3) maximizing impact of research; (4) inclusive integrated interventions; (5) evidence-informed measurement and outcomes; and (6) reducing weight biases.
Within each theme area, participants identified potential challenges and opportunities related to (1) clinical practice and education; (2) research (subareas: funding and methodological issues; client and family engagement issues; and targeted areas to conduct research); and (3) policy-related issues and topic positioning.
Recommendations emerging from the workshop’s multistakeholder consensus activities included:
Children’s and families’ needs must be integrated into prevention and treatment programs, taking into account the additional caring commitments and environmental challenges often experienced by families of children with physical disabilities. Guidelines need to be developed regarding how best to engage children/families meaningfully in designing both clinical interventions and health promotion research initiatives.
Research in obesity and health in children with physical disabilities should be guided by a conceptual model, determining both common and unique determinants of health and obesity compared with their typically developing peers. A conceptual model enables existing knowledge about obesity prevention and management from other populations to be integrated into approaches for children with physical disabilities where appropriate, as well as the identification of areas where disability-specific knowledge is still needed. It is critical that any such model incorporates social and environmental factors that can affect both weight and health, rather than locating responsibility within the individual by default.45 The alignment of our model with the ICF ensures that our approach remains truly biopsychosocial.
Valid, reliable, clinically appropriate, and acceptable outcome measures are urgently needed in order to monitor children’s weight and health, and identify overweight and obesity, where conventional outcomes (e.g., BMI) alone have been shown as suboptimal.
As the authors note,
“Canadian researchers are now well positioned to work toward a greater understanding of weight-related topics in children with physical disabilities, with the aim of developing evidence-based and salient obesity prevention and treatment approaches.”
Hopefully, they will now find the funding required to do the work.
A key reason for the Canadian Obesity Network to roll out its public engagement strategy, is not just provide a source of credible information on obesity prevention and treatment but also to provide a forum for the prospective of those living with obesity.
That this perspective is often lost in the obesity debate, is highlighted by a thoughtful commentary published in JAMA Internal Medicine written by Fiona Clement, PhD, from the Department of Community Health Sciences, University of Calgary, and has herself struggled with excess weight for most of her adult life.
Clement, whose BMI (at 31.8 kg/m2) barely fits the “obesity criteria”, notes that,
“…this article is the first time I have told my BMI to another soul. I have never shared my BMI with my husband, my friends, nor, importantly, my physician. Given that I am an otherwise healthy 35-year-old woman, it is shocking that what is probably my only health concern has never been talked about within the privileged space of my physician-patient relationship.”
Her reasons for not talking about this are not surprising,
“Obviously, this is an awkward conversation for both the patient and physician. Weight is a tough subject, loaded with stigma, self-esteem, worthiness, and beauty issues. Despite guidelines recommending weight management counselling, the conversation is not happening regularly. Like many hard conversations, it requires compassionate listening and sympathy on the part of the physician, courage and humility from the patient.”
This problem is well recognized, which is exactly why the Canadian Obesity Network’s 5As approach to obesity management emphasizes the tact and skills needed to initiate this conversation (ASK for permission, be non-judgemental, do not make assumptions).
As to the use of appropriate obesity management strategies, Clement essentially opted for the most common “do-it-yourself” approach of “eat-less-move-more”, which as ample research shows is rarely a sustainable strategy. Not surprisingly, the weight she lost came back when, as she says, life happened.
Clement writes about the information she would want presented before she made an informed decision to pursue any of the proposed interventions.
This is exactly what the 3rd A in the 5As of Obesity Management is about – ADVISE. This is where, following the ASK and ASSESS, the health professional would offer their advice – tailored to the individual.
Given that Clement barely meets the BMI criteria for obesity and has, as she states, no weight related health issues, she would at best be considered to have Stage 0 obesity according to the Edmonton Obesity Staging system.
At this stage, the risk (not to mention the cost) of pharmacological or surgical treatments would by far outweigh any potential benefits. Indeed, the focus would be to first and foremost prevent further weight gain by addressing any underlying contributing factors while living the healthiest life she can enjoy (best weight).
This is apparently the course of action that she chose, wisely it seems.
Indeed, given that she has Stage 0 obesity, it is not clear that she would have any real health benefit from attempting to or sustaining weight loss – obesity management should never be about treating numbers on a scale.
Perhaps if Clement had a higher obesity stage, say Stage 2 with diabetes, fatty liver disease or sleep apnea, the advise may be different. In that case, given the substantial risk associated with these conditions, pharmacological or surgical options (especially if her BMI was higher that 35) may well be reasonable additions to her behavioural change.
Thus, Clement is right in noting that interventions have to be individually tailored and a frank conversation about the risks and benefits of treatment between her and a health professional who understands obesity needs to happen (unfortunately, the latter is difficult to find).
With obesity as with other diseases, the question is always the same – at what stage of the disease does the risk of treatment outweigh the risk of not-treating (or not-treating aggressively enough). Whether the problem is diabetes, arthritis, or cancer – the question of risk-benefit ratios must always be seen in the context of the individual.