GPs can successfully raise the sensitive issue of obesity

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obesitywebGPs who raise the issue of their patients’ obesity in the surgery will not offend them and are likely to help them reach a healthy weight, a UK study has shown.

The report says doctors are notoriously nervous of telling people they are overweight and worry that initiating any discussion will lead to a long, fruitless conversation about failed diets and eating habits that will go on long beyond a 10-minute consultation.

But a trial of a 30-second intervention in which the GP suggests the patient’s weight may be affecting their health and offers them a place on a weigh-loss programme reveals advice can make a major difference.

More than 130 GPs who took part in the trial, involving more than 1,800 patients, were asked to start a conversation that might go like this:
GP: While you’re here, I just wanted to talk about your weight. You know the best way to lose weight is to go to (a weigh-management programme such as Slimming World or Rosemary Conley) and that’s available free on the NHS?
Patient: Oh?
GP: Yes, and I can refer you now if you are willing to give that a try?

The patients were randomly assigned to be offered either an NHS-funded place on a 12-week weight-management programme or advice to lose weight. The researchers found that 77% of those offered a weight-management programme said yes, and 40% went to all the sessions. At the end of a year, those people had lost 2.43kg (0.38 stone) on average, while those given advice by the GP had also lost weight, but less, at an average of 1.04kg.

Professor Paul Aveyard from the University of Oxford, who is a practising GP, is quoted in the report as saying that GPs do not talk to patients about their weight unless that is the reason they have come to the surgery. “We weigh people and that’s it. Whereas with smoking, every time we see them, once a year, we have to tell them effective ways to stop smoking,” he said.

Trials from the 1970s had shown that if GPs tackled people about smoking, they were more likely to quit. But this is the first study to see whether it works in obesity too, he said. “GPs worry a lot about offending people. It is a very personal thing. Secondly, they do worry that the conversation will go on a long time and not actually lead anywhere,” he said. There was also the wish not to take on one more of society’s ills, Aveyard said. “The GP might easily say this is more than my job is about,” he added.

The average BMI of those in the trial was 35 – a BMI of over 35 is considered severely obese – which meant that people needed to lose 20 to 30 kilos to get down to a healthy weight.

Dr Iain Turnbull, a GP in Swindon who took part in the trial, said one of the main reasons they do not mention weight when somebody arrives with a cough or a chest infection is constraint on time. “We don’t really have the opportunity to talk to them about weight management on top of everything else,” he said. “The reality of modern GP practice is that it is a terrifically high-pressured and time-intensive specialty.”

But the report said, the study enabled him to keep the discussion brief and his patients were not offended. “I didn’t have any negative feedback from patients. They seemed quite pleased that I’d brought up the issue.”

Boyd Swinburne and Bruce Arroll from the University of Auckland in Australia have said the study calls for a rethink of how obesity is tackled in primary care everywhere. “It is surprising that this is the first study in primary care to investigate a brief intervention for obesity, perhaps reflecting the nihilism about weight loss that pervades medical care,” they write.

Tam Fry, spokesperson for the National Obesity Forum, said in the report: “The paper effectively runs a coach and horses through the excuses that GPs in general have trotted out when challenged to talk to their patients about losing weight. Their principal argument has been that it’s pointless since no good weight-loss programmes exist. Nonsense. They do and have done so for years.

“Now that the evidence is out in the open, family doctors should take action to prevent obesity and weight-related health problems that clog up their waiting rooms.”

Dr Alison Tedstone, the chief nutritionist at Public Health England, said: “It’s important that GPs talk to their overweight and obese patients about losing weight and help them to find further support, as many do already. An extra 30 seconds could make all the difference; it doesn’t take long and can be raised in a supportive and sensitive manner.”

Summary
Background: Obesity is a common cause of non-communicable disease. Guidelines recommend that physicians screen and offer brief advice to motivate weight loss through referral to behavioural weight loss programmes. However, physicians rarely intervene and no trials have been done on the subject. We did this trial to establish whether physician brief intervention is acceptable and effective for reducing bodyweight in patients with obesity.
Methods: In this parallel, two-arm, randomised trial, patients who consulted 137 primary care physicians in England were screened for obesity. Individuals could be enrolled if they were aged at least 18 years, had a body-mass index of at least 30 kg/m2 (or at least 25 kg/m2 if of Asian ethnicity), and had a raised body fat percentage. At the end of the consultation, the physician randomly assigned participants (1:1) to one of two 30 s interventions. Randomisation was done via preprepared randomisation cards labelled with a code representing the allocation, which were placed in opaque sealed envelopes and given to physicians to open at the time of treatment assignment. In the active intervention, the physician offered referral to a weight management group (12 sessions of 1 h each, once per week) and, if the referral was accepted, the physician ensured the patient made an appointment and offered follow-up. In the control intervention, the physician advised the patient that their health would benefit from weight loss. The primary outcome was weight change at 12 months in the intention-to-treat population, which was assessed blinded to treatment allocation. We also assessed asked patients’ about their feelings on discussing their weight when they have visited their general practitioner for other reasons. Given the nature of the intervention, we did not anticipate any adverse events in the usual sense, so safety outcomes were not assessed. This trial is registered with the ISRCTN Registry, number ISRCTN26563137.
Findings: Between June 4, 2013, and Dec 23, 2014, we screened 8403 patients, of whom 2728 (32%) were obese. Of these obese patients, 2256 (83%) agreed to participate and 1882 were eligible, enrolled, and included in the intention-to-treat analysis, with 940 individuals in the support group and 942 individuals in the advice group. 722 (77%) individuals assigned to the support intervention agreed to attend the weight management group and 379 (40%) of these individuals attended, compared with 82 (9%) participants who were allocated the advice intervention. In the entire study population, mean weight change at 12 months was 2·43 kg with the support intervention and 1·04 kg with the advice intervention, giving an adjusted difference of 1·43 kg (95% CI 0·89–1·97). The reactions of the patients to the general practitioners’ brief interventions did not differ significantly between the study groups in terms of appropriateness (adjusted odds ratio 0·89, 95% CI 0·75–1·07, p=0·21) or helpfulness (1·05, 0·89–1·26, p=0·54); overall, four (<1%) patients thought their intervention was inappropriate and unhelpful and 1530 (81%) patients thought it was appropriate and helpful.
Interpretation: A behaviourally-informed, very brief, physician-delivered opportunistic intervention is acceptable to patients and an effective way to reduce population mean weight.

Authors
Paul Aveyard, Amanda Lewis, Sarah Tearne, Kathryn Hood, Anna Christian-Brown, Peymane Adab, Rachna Begh, Kate Jolly, Amanda Daley, Amanda Farley, Deborah Lycett, Alecia Nickless, Ly-Mee Yu, Lise Retat, Laura Webber, Laura Pimpin, Susan A Jebb

The Guardian report
https://www.theguardian.com/society/2016/oct/24/gps-should-not-worry-about-offending-obese-patients-finds-study
The Lancet article summary
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31893-1/fulltext


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