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Pr Susan Jebb and Gary Frost : Obesity, diet and Primary Care

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MD-FM INSIGHT Tuesday 27 August, 2013

 

«How primary care doctors can best help obese patients?»

 


PETER GOODWIN:

Hello! Welcome to MD-FM — the first medical web radio. I’m Peter Goodwin.

 

Today’s MD-FM is a debate devoted to the practical issues on just how medical doctors can be helped to tackle their patients’ weight problems. They may know in theory but in practice its difficult to make it happen. Some of the issues? What can doctors do practically?

How can they access the increasing range of resources available that can work? How they can help their patients when they have lost weight to maintain the efforts and keep up that achievement in the long term? These are some of the issues and my studio guests are, Susan Jebb, Head of Diet and Population Health at the Medical Research Council’s Human Nutrition Research Unit, in Cambridge, and Gary Frost, Chair of Nutrition and Dietetics, at Imperial College and Head of the Nutrition and Dietetic Research Group.

 

Susan, I know you’re really interested in the fact, why it is that doctors should be in the front line actually to get involved because it’s very easy for doctors to think: “I don’t want to get involved”?

 

SUSAN JEBB:

Obesity is a huge and a growing problem for people across Europe, and I think that doctors have really got to wake up to the contribution that obesity is making to many chronic diseases: diabetes, high blood pressure, vascular disease and so forth. It’s a huge cause of preventable mortality. A big study done by the University of Oxford looked at over 900,000 people taking part in cohort studies, and what they showed is that BMI — body mass index — increased. Premature mortality also increased. So every five-unit increase in BMI was associated with about a 30% increase in the risk of premature death. Those deaths are mostly from vascular disease because we know as BMI goes up, systolic blood pressure goes up, insulin resistance goes up, your HDL cholesterol tends to come down but all other cholesterol fractions go up. So, tackling obesity can really help to address a whole raft of metabolic disturbances.

 

PETER:

So it’s at the core or medical care then Gary?

 

GARY FROST:

Absolutely, at the core of medical care. I think one of the issues is that people or physician and health care practitioners, often perceive that it’s really difficult, that they’re going to fail because the perceived failure rate is so high. And that’s perhaps over-egging what the actual outcomes actually are, and most people in the acute phase will loose weight.

 

SUSAN:

We’ve also got fantastic evidence now from things like some of the big diabetes prevention trails with very large numbers of people, who are randomised either to usual care or to a more intensive lifestyle intervention. What happens is typically people lose six or seven kilos in the first six months, they keep it off for a short while, but gradually weight is regained. But in spite of that weight regain, the incidence of diabetes is more than halved. That’s incredibly important risk reduction, and that risk reduction continues even when their weight is returned to the same level as the control group, presumably because they’ve made positive changes in their lifestyle.

 

GARY:

And what seems to be important about these interventions its a structure — about having a structure to what you’re offering people, and actually giving a degree of educational support.

 

PETER:

So there’s real evidence that the doctor is important and can be a lynchpin of making progress. But the doctor is not on his or her own is he, there’s lots of outside resources, I suppose it’s pretty daunting for a doctor to take on obesity in the community but what outside resources and what help can doctors have?

 

SUSAN:

I totally understand why this is a daunting problem for doctors because it effects so many people and it’s a chronic relapsing condition. But I think doctors shouldn’t underestimate the impact they have on patients when they start to explain, that perhaps they’d be able to reduce some of their blood pressure medication if they were able to successfully lose weight, or that they could actually avoid developing diabetes. So doctors can be vital to that initial motivation for the patient to tackle their weight. And what doctors then need to do is help them to access the support they need perhaps in the community, there are lots of good resources on the web or indeed practical support groups, community based groups which can help.

 

PETER:

Do you see this as a cost saving measure? Can the practice save money by helping patients?

 

GARY:

Absolutely! All of the evidence that we have, admittedly not huge amount, but evidence from a large UK non-randomised kind of audit shows that, if people loose weight, the drug prescription rate falls, the number of visits to actual GP practice falls and that all gets turned into a cost benefit. And even if the person gains weight in three or four years, the cost benefit is still there.


PETER:

As time goes by, we come to accept quite a level of overweight and obesity in the community, is all of it bad? What about the difference between morbid obesity and just ordinary obesity, how much evidence is there that reducing [weight] really does bring benefits?

 

SUSAN:

Well of course the fatter you are, in general, the greater the risk from a whole range of conditions. But there is a lot of inter-individual variability, and this is where doctors are very well placed to consider other factors in peoples lives, other aspects of their lifestyle, their family history and so forth and actually to prioritise those patients who are going to be at the greatest risk. We shouldn’t think that that is necessarily always the patients who are the largest, in fact, in public health terms having a small impact on a large number of people who are only modestly overweight, may be just as important as treating a small number of people who are morbidly obese.

 

GARY:

And you have to remember the adult population year on year is gaining weight. So those people who were perhaps on the borderline at the present time of being overweight, in a few years time will be in the middle of being overweight and so the progression continues. So again, finding fixes to the large number of people is incredibly important.


SUSAN:

I think there’s another important point to that Gary too, which is people tend to gain weight as they get older and I think sometimes doctors tend to defer intervention for too long. And I think perhaps we should be intervening in a much earlier stage, because we know it’s easier for people to loose a few kilos than to loose tens of kilos.

 

PETER:

So to summarise, which patients should be targeted? If you’re not going to target all of them which should you go for?

 

SUSAN:

The ones who are at the highest risk, the ones who are presenting to you with other complications, who are on the verge of needing treatment for their blood pressure, who are on the verge of diabetes, or who have strong family history. Those patients are likely to be the most motivated and those are the one in where you are most likely to see the greatest immediate health gains.

 

GARY:

But I think the practices need to think about how they get the messages over to the larger group of people, and that might be using something more than just face to face, it might be general messages within the practice that raise the awareness.

 

PETER:

And some of the people who are going to be overweight when they are older are not even seen by the doctor, so how does a doctor take on that level of commitment?

 

SUSAN:

We have to be realistic, doctors alone are not going to solve the entire public health problem of obesity, but they do have a place within that and I think doctors need to start by dealing with those people who are at the highest medical risk, and of course acting as advocates in their local community for more general health improvement messages.

 

PETER:

So what are the options though that the doctor can use, the actually tools at his or her disposal for combating obesity?

 

GARY:

Well I think there are many, I think getting their own systems in place within the general practice is incredibly important. Getting consistent messages throughout the general practice is important, there’s nothing worse, nothing destroys a health message more than people giving variable health messages. So if you come in and I say to you the most important thing for you to do is to miss out butter, and the next person says that’s a load of rubbish, you need to do X and Y, it destroys that underlining health message, so having simple messages that are supported by everyone in the practice is important.

 

SUSAN:

I completely agree with the importance of consistent advice but you also need an overarching care pathway, so that there is a protocol which says what is the most appropriate treatment to start with for different patients. For the most severely obese, well for everybody, lifestyle interventions, behavioural interventions ought to be the first-line therapy and people ought to be having some structured organised advice over diet and physical activity. But if we want to look at second and third-line treatments for the most severely obsess patients at the highest risk, bariatric surgery is shown to be both clinically effective and cost effective but is only going to be suitable for a small number of people.

 

PETER:

There's evidence that bariatric surgery actually does reduce risks its not just cosmetic, how much of a risk reduction does it produce and how does that compare with reducing weight by other means and how sure are you you’re going to benefit your patients overall they’re going to live longer if they loose weight?

 

GARY:

Well live longer is a really difficult one, I think we need to move that to one side…

 

SUSAN:

But we do know after bariatric surgery the risk of fatal cardiovascular disease is about halved.

 

GARY:

Yes, and the risk of diabetes disappears. So from those two points of view, it’s undoubtedly very important.

 

PETER:

Now we are all governed by our genes, people do actually vary, some people respond to diets and different foods more than others and get fatter, also I was looking again at one of your colleagues, Tony Goldstone, and he said there are many ways actually of getting fat, perhaps we can hear what Tony had to say:

 

TONY GOLDSTONE:

Of course obesity is just the end-point, we measure someone’s height or weight, or if we’re being more sophisticated we measure their fat using machines — or MRI machines or impedance machines. But that’s just the endpoint, that just where they’ve ended up. The route they’ve got there, can be quite varied and I think part of the problem is that we assume that everyone gets to the same point of being over weight through over eating for the same reason, lack of self control, that’s what the general public think. But I don’t think that’s a very fair analysis of the multitude of the ways in which we can get there. So we can get there, maybe some people crave high calorie foods more, some people maybe get less pleasure from high calorie foods and have to eat more to get the same pleasure. Some people may be impulsive, so they’re less able to wait to get the food later on, some people may be more compulsive, i.e. they’re unable to stop repeating the same action. Some people overeat when they are stressed or emotionally upset and that may be another contributor.

 

PETER:

This makes the doctor’s job really difficult if different people get fat for different reasons…


GARY:

Yes, but I think it comes back to what Susan said before, its about having a care pathway in place and understanding peoples responses to different messages that they’ve been given. Practically, what you want to try and do, is to move people slowly into a negative energy balance so they loose weight.

And that pathway is very difficult it needs actually a degree of support and that might change because as Tony said, there might be compulsive eaters but this should not put people off trying to do this and I think the problem with those messages is they put the general practitioner off.

 

SUSAN:

What’s interesting is that although I totally agree there are 101 reasons why people gain weight, in fact actually what we find is that if you put a large number of people onto a weight loss plan in general they all lose some weight. Some are more successful than others but we’ve not yet found a way of, if you like, tailoring a diet to a particular genotype of phenotype. In the meantime, what we know is that adherence is what really matters. There are lots of different diets out there, high protein, low fat, low carb all kinds of things. What matters is not so much the dietary prescription but adherence, it’s about finding a diet plan which has got a controlled calorie intake and which people can stick to, and that depends on their lifestyle. And so a good health professional will be able to help patients make a choice about which regimen to follow, which the patient believes is going to be most suitable for them. It’s a negotiation.

 

GARY:

One of the commonalities about the actual studies that have shown long-term benefit of weight loss, is that degree of professional support or support at the beginning is important. The less support you get, the less likely it is to be successful.

 

PETER:

How does a doctor practically do that support?

 

SUSAN:

Well I totally agree with Gary. Support is vital, doctors can get people started, they can help them to access support in the community, but the other thing they can do — especially family doctors, who are seeing these patients regularly, because many of them have other health things — is that they can weigh them each time they see them and they can provide the patient with feedback. That might be feedback which says: “You’re doing incredibly well,” because — actually — people are often underwhelmed by their success, but we know even small differences have big clinical benefits, so doctors can reinforce the value of that, or at other times they can re-give those motivational messages to remind patients how important this is. So follow up gives a bit of accountability to the patient from somebody they trust and respect, and it also gives them some feedback: and those are both things which are going to help them succeed.

 

GARY:

One other thing is that you have to somehow pull out of the person what they want to achieve and why they want to achieve it, which might have nothing to do with a medical condition but the actual driver to lose weight might be something incredibly personal, and understanding that can unlock the change in the actual pattern of weight loss.

 

SUSAN:

I think doctors need to think much more about helping people to change their behaviour in a general way, using all the other skills that doctors have to help people to change. Skills they’ve learnt in relation to smoking cessation, or in relation to controlling excessive alcohol and so on. To harness those skills, rather than worrying that they somehow don’t have the detailed nutritional or physiotherapy background to recommend specific exercises. Actually that’s mostly not what its about. When we talk to patients about what they want from their doctor, they don’t so much want information: actually most patients think they’ve got a good idea about what they should do; they want support — and they want the motivation that this is going to improve their health.

GARY:

And if you go back to those successful trials, the messages that are given are generic and they’re simple. They’re are not complicated nutritional messages…


SUSAN:

And they’re not personalised!

 

GARY:

Absolutely! But what they get is the face to face support.

 

PETER:

And could I ask you about a trial because if you’ve lost weight you want to keep it off, and Susan you were involved with the Diogenes trial, an intervention study to help people to maintain weight loss. How easy was that, I don’t think it was very easy was it?

 

SUSAN:

Keeping the weight off once you’ve lost it is a huge challenge, in fact I’d say it’s a bigger challenge even than losing weight: lots of people successfully lose weight but its keeping it off that’s hard! And this is where you get back to those core components of diet and lifestyle, which help people to avoid weight gain in the first place. In the Diogenes trial, we did show that a diet which had a slightly higher proportion of protein, which was low in fat, and which had a lower glycemic index, appeared to be associated with somewhat better weight control in the long-term. But that’s really getting back to the core components of a healthy diet, which are going to help everyone prevent weight gain.

 

PETER:

But there are outside agencies — I think you both referred to this —who can help the doctor. So could you summarise — which ever country you live in — what those agencies might be?

 

GARY:

Perhaps the biggest one is “Weightwatchers”, isn’t it to put a name to them. And again I think the relationship between weightwatchers and health or such groups as weightwatchers needs to be improved. They offer a structured input that for most people actually helps, if the practice or doctors don’t have time to manage people on a face to face basis, then these organisations are critically important in helping people change.

 

SUSAN:

Sure, we’ve done some research which has shown that referring patients to one of the large established quality assured commercial providers, can lead to about twice as much weight loss as trying to treat them in the practice and that’s incredibly important. But it’s the partnership between the provider and the doctor which is really crucial. The doctor provides that initial motivation, refers patients to the provider for that practical advice and that ongoing support which is hard to do in general practice. But then the doctor contacts the patient again follows them up to provide that accountability and that medical feedback. And I think there may be other schemes which were effective, but one thing doctors can do on behalf of their patients, is look out for the research evidence that shows what works because of course we must only be referring patients to external providers where there’s clear evidence that they’re effective.

 

PETER:

Could I get both of you to summarise what you feel we’ve achieved in this discussion about what doctors can actually physically do about this looming and very frightening problem of obesity in the community? Could you draw up some conclusions Gary?

 

GARY:

Well to start the ball rolling, the first thing is: engage with people. Is: not to be frightened of actually bringing up the subject of weight. To have simple messages within the practice that go across the practice to support people. And — when people come back  — is: to raise the issue again — it’s not a forgotten issue; is: to actually give people support and encouragement.

 

SUSAN:

I agree with all of that, and I think doctors need to recognise that obesity underpins so many of the other problems that they’re dealing with, not just the cardiovascular disease and diabetes but, infertility, back pain, sleep apnoea, respiratory problems a whole raft of medical conditions. And doctors have an amazing relationship with patients, they’re trusted and they’re authoritative and actually a word from a doctor can often unlock a patient’s own desire to do something about their weight, they’ve got a pivotal role to play.

 

PETER:

And psychology lies at the heart of it; and your medical training too?

 

SUSAN:

Absolutely; but your relationship with your patient is going to be vital, and that’s going to help you to individualise the way you engage with the patients and help them to identify what it is which matters most to them, that can be really crucial.

 

PETER:

Our debate has to draw to a close for now, we’ll be very pleased to hear any comments. If you want to write in and let us know what you think about what you’ve been hearing on this edition of MDFM, that would be great! That’s all for now, but you can find details of how to contact us — and we’ve got the practice sheets and nutrition summaries: and you can get those by downloading them from the MDFM website. So it’s goodbye from Doctor Susan Jebb, from the MRC Nutrition Unit in Cambridge, and Professor Gary Frost from Imperial College, thanks to both of you. And thank you to Danone for supporting this programme, we’ll be back again very soon with more MDFM on the topic of nutrition, until then from me Peter Goodwin, goodbye!

 

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