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GPs are attempting to support patients living with obesity while working in a system that has no contemporary clinical guidelines and that is underfunded to provide effective care. GPs are often trying to make it all work for patients without financial means where the prevalence of obesity is highest. It just isn’t possible.
OBESITY continues to be one of the most perplexing and complex health problems. It has been clear for some time that people living with obesity want more support from their general practice, but what does this look like in reality? And how effective can general practice be in the current health care system?
Our recent meta-analysis published in the BMJ on the effectiveness of weight management in primary care showed that people who received help from their general practice lost a mean 3.7 kg – 2.3 kg more than people who did not receive help from their GP. Our study examined 27 randomised controlled trials that included data from 8000 people and a large variation in the types of interventions offered. Programs lasted from 3 months to 3 years, most were offered as in-person visits, some offered structured physical activity or dietary plans, and some involved nursing and allied health visits. The two programs that included a very low energy diet (VLED) alongside intensive support visits were associated with the greatest amount of weight loss.
With all of this variation, one thing was clear – more intensive programs with higher numbers of visits were more effective. Those programs that offered at least 12 contact visits were associated with a higher amount of weight loss. Importantly, our meta-analysis showed that 80% of people maintained their weight loss at 2 years when they had been assisted by their general practice.
Some may say that this small amount of weight loss (3.7 kg) seems like a useless waste of time. But the Australian Institute of Health and Welfare has reported that a reduction in BMI of 1 kg/m2 across the at-risk Australian population would result in a 14% reduction in the national disease burden due to overweight and obesity. A small amount of weight loss across a large population leads to population benefit.
This population level benefit is an example of the primary care-public health interface that has become increasingly apparent during the ongoing global pandemic. Although our meta-analysis focused on weight, as this is the most common primary outcome in obesity research, it is still possible for patients to improve their health, wellbeing and long term outcomes by becoming more active or improving their diet independent of weight loss.
Obesity is defined by the WHO as excessive fat accumulation that may impair health. Using this definition, it is clear that obesity is a chronic health condition that should be supported with the same health care access that is available for other chronic health conditions.
Currently under Medicare, patients with a chronic condition that is likely to be present for 6 months or more can be supported with a chronic disease management plan. Alongside these plans, patients can be eligible for up to five rebatable allied health visits per year. This situation is clearly inadequate for effective obesity management when we consider the findings from our meta-analysis where at least 12 visits are required. Further, a 2021 Grattan report found that only 56% of allied health services were bulk-billed and each visit on average cost patients $55.
This cost of allied health appointments is only the tip of the iceberg when we consider equity in obesity management across Australia. Over 90% of all bariatric surgery procedures are done in the private system; private fee-paying clinics provide wrap-around care for those who can afford it; no medications are subsidised on the PBS for obesity. This is despite obesity affecting more people in the lower income brackets.
It is more than 50 years since the Welsh GP Julian Tudor-Hart wrote his sentinel paper on the inverse care law – the principle that the availability of good medical or social care tends to vary inversely with the need of the population served – and obesity care in Australia continues to be a stark real-world example of the law in action.
The 2022-2032 National obesity strategy was released in March 2022. Primary health care, which includes general practice, is mentioned as playing an important role in obesity management and it is reassuring to see mention of the current inequities in care. However, the NHMRC clinical practice guidelines have been rescinded as they are out of date and there are no publicly clear plans for them to be updated.
GPs are attempting to support patients living with obesity while working in a system that has no contemporary clinical guidelines, is underfunded to provide effective care, and in which they are often trying to make it all work for patients without financial means where the prevalence of obesity is highest. It just isn’t possible.
We need system reform and change to provide effective and equitable obesity care in Australia.
Dr Liz Sturgiss is a clinical GP, NHMRC Investigator and primary care researcher. She is a Senior Research Fellow in the School of Primary and Allied Health Care, Monash University, and Visiting Fellow at the Australian National University. She has experience in implementation research in primary care with expertise in the complex area of obesity management. Liz leads an emerging research program on the management of complex and stigmatised health issues in primary care focusing on translating guidelines into real-world practice. Her research is based on theoretical principles from behaviour change and implementation science.
Dr Claire Madigan is a Senior Research Associate in the CLIMB team at Loughborough University, UK, focusing on weight management interventions. Prior to her academic career, she worked in public health, commissioning weight management services. Claire completed her PhD at the University of Birmingham on behavioural weight management interventions in primary care and then went on to hold positions at the University of Sydney and University of Oxford.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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Educating the general population about the prevention and the consequences of Obesity thru wide media information can be effective learning process and do what action the people can do to avoid this chronic condition.
Most women on hormonal pills seems also overweight that they may not know it.
Most individuals on psychotropic medications for sometimes were also noted to be overweight or obese as well.
New and advanced technologies people uses nowadays limits or reduced active movements of our physical and mental activity leading to obesity.
There are many other negative factors causing Obesity, but the more they know about it in the early age probably the more it will be avoided later on.
Over focus on weight and obesity is only increasing disordered body images and driving patients away for health professionals. A focus on weight loss simply encourages patients back on the never ending diet cycle and there are almost no longer term weight loss mechanisms proven effective beyond bariatric surgery. Its baffling that evidence based interventions are encouraged until it comes to weight. A focus on healthy eating/how to make healthy choices is what is needed not a focus on the scales. Sugar tax is also not helpful, rather should try a tax program that follows the Brazilian dietary guidelines which rate foods based on the level of processing. Highly processed foods should have higher taxes compared to minimally processed foods. Don’t blame a single nutrient.
It is amazing that GPs are constantly bombarded to do something about patients weight, but when effective medication such as Semaglutide is created ( and yes it is the most effective treatment that I have seen, second only to Bariatric surgery), GPs and patients are barred from using it- due to cost issues for patients and poorly thought out PBS listing. This is a ridiculous situation.
As GPs were have seen patients who have tried everything and their next step is a 15,000 operation -WE KNOW SEMAGLUTIDE WORKS EXTREMELY WELL FOR A SIGNFICANT PROPORTION OF THESE PATIENTS.
I have seen this time and time again prescribing this for both diabetics and non diabetics.
If a diabetic patient has high BP- we have a duty to treat it! If a non diabetic person has high BP -we have a duty to treat it!
If person is overweight, whether diabetic or not, (and they have failed conservative management)- WE OUGHT TO BE TREATING IT.
The cost of NOT treating obesity is huge and we already have a hospital system in crisis that really has no capacity to treat many more patients.
These medications are a game changer as they stop people craving sugar/food.
Realistically we cannot legislate food or sugar away. Time is not going to turn back to before we had cars and roads and had to walk everywhere. We need better PBS listings for these medications unless the government wants to cover Bariatric surgery- anything less if not treating the problem seriously.
It’s interesting as observed above the association between low SES and obesity. A century ago it was the wealthy who were obese and the poor never were, as the latter could not afford unlimited high calorie food. Now, the wealthy can afford the higher quality fresh food which is more expensive than the high carb high sugar processed food.
The answer is not more medications which exaggerate insulin resistance and make matters worse.
Too many years have been wasted on the ineffective “low fat diet” messaging. A sugar tax is needed yesterday.
The pharmaceutical industry has now created semaglutide, tirzepatide and cagrilintide which will produce sustained weight loss of around 20 kg in obese patients.
Drugs are are clearly the best solution and hopefully the cost and availability issues can be dealt with as soon as possible.
Excellent article outlining some of the problems underlying treatment of obesity.
It is a chronic progressive disease which shortens peoples lives and is associated with around 200 co morbidities and still the government pays lip service to the ongoing management.
As stated in your article it mainly affects lower economic social classes who can ill afford the cost of medications
Simplistic Observation but true:
Excess calories in, in the setting of constant gut disruption of the healthy gut microbiome by processed and fat laden fast foods and sugar drinks that is directly associated with a lack of exercise and the induction of the highly pathological Metabolic Syndrome inevitably leading to excess calories ‘on’ and early mortality.
Not rocket science.
Digging one’s grave with one’s own teeth with the help and constant encouragement of industry designed crap diets..
Rational Answer: Treat the disease source with Public Health interventions that are likely to be acceptable to the public.
This article is effectively just advocating more and more funding for wasteful bandaid treatments rather dealing directly with the multinational corporate gorillas in the room.
Look back at street scenes in this country before the 1970s (i.e. BKFC; Before KFC). Rarely an obese person in sight..
Thanks for this excellent piece. You demonstrate the effectiveness of primary care (same for smoking and alcohol interventions) – the ubiquity of the inverse cafe law in our “egalitarian” Australia and the abject failure of governments (and the medical profession) in the last 15 years to take on the commercial vectors of obesity – ultra processed food and beverage corporations.
The evidence shows obesity is mostly related to eating habits and secondarily lack of activity, in particular high sugar “treats”, fast food etc. We should be tackling the issue at the source, rather than expensive bandaid solutions. The billion dollar sugar industry targets kids (mainly via parents) from an early age making it normal to eat this diet and we are just sitting by and letting it happen.