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.

Edmonton, Alberta