Stewart Truswell: Weighty barriers

GP advice on nutrition has powerful advantages in dealing with obesity. However, there are three main barriers to GPs having more active involvement in nutrition advice to patients.

First, time is short, but GPs can see their patients several times a year, so a simple message can be reinforced.

Second, doctors have little training in nutrition, but information is becoming available via medical software and there are books on nutrition written for GPs.  Doctors are trusted. They are not selling a food product, unlike so much information patients receive via various media.

Third, patient compliance with dietary prescription from their doctors has been disappointing, especially for obesity. It is much easier to take a medicine.

As the recent international workshop on nutrition work in general practice, held in The Netherlands, made clear, the problems facing GPs in Australia in treating and advising overweight and obese patients are international problems.

Only a minority of people who are overweight when they see their GP are at a stage in life where they want to change their diet. If they do, the doctor can provide advice and continuing support.

However, most patients have medical or social problems that they are more worried about than their weight.

Consequently, weight loss management can be part of the background management of the patient’s condition, but it is the distressing symptoms or problems that need treatment first. Ultimately, it is the individual patient who has to make the decision to work on weight reduction, not their doctor.

Sir Pereira Gray, former president of the Royal College of General Practitioners, has outlined research that found GPs’ nutritional advice — broad simple principles — is as effective as advice from dieticians.

So, it is reassuring that family doctors are now more and better prepared to treat overweight and obese patients.

In 1995, most GPs had or expected little success in treating obesity. In 1998, one of the important conclusions from the international workshop on nutrition in general practice was that “overweight is not the fault of the GP”. The epidemic of obesity which built up during the 1980s was a problem for the wider society, politics, economics and education.

Growing and widespread public health concern about obesity has made it acceptable for GPs to now to raise the matter of weight, body mass index (BMI) and waist circumference with their patients.

Present practice in primary care is well illustrated by the 2010 Practice Guidelines of the Dutch College of General Practitioners. Those guidelines say that doctors should examine and treat patients who ask for help with weight reduction, as well as overweight or obese people with comorbidity, especially diabetes, cardiovascular disease and sleep apnoea. The Royal Australian College of General Practitioners also provides helpful guidelines.

Treatment is essentially a reduced-calorie diet plus regular moderate exercise. All diets result in more or less equal weight reduction. Medication is not recommended, but cognitive behaviour therapy can be helpful. Follow-up is important.

The doctor should make it clear to the patient that as little as 5%–10% weight reduction can result in considerable health gain. Normal weight in adults is often not achievable, particularly in the obese.

In Britain, some practices have participated in the Counterweight program. One of the GPs in the practice and the practice nurse take a special interest in those obese patients who agree to try treatment. An evidence-based protocol is used and supported by external advisers.

After an audit of the health burden of obesity in the practice, the practice nurse receives training and the GPs identify suitable patients.

In Scotland, where Counterweight is funded by the UK government, around 35% of patients who attended follow-up for 12 months had maintained a weight loss of 5% or more.

Mild obesity is easier to treat than severe obesity and prevention of gross obesity is much easier than cure.

Doctors should try to help their overweight patients not to put on any more fat, even if they don’t manage to lose weight.

Professor Stewart Truswell is emeritus professor in the School of Molecular Bioscience at the University of Sydney.

This article is based on the proceedings of the 6th Heelsum international workshop on nutrition work in general practice/family medicine/primary care, published in Family Practice. These workshops are held every 3 years in Heelsum, a small town close to the universities of Wageningen and Nijmegen, in The Netherlands.

Posted 18 June 2012