A population health approach in general practice could help tackle obesity, a complex issue that carries a considerable cost to the individual, NHS and wider society. Ishraga Awad, Sarah Cuschieri, Michelle A Miller, and Claire Beynon from the Faculty of Public Health Special Interest Group for Primary Care and Public Health explain how in the second of two articles exploring the issue.
The first article explored the context of obesity and the wide-reaching implications of the condition for the individual and the health service. It is a condition defined by its complexities. Given the myriad factors contributing to obesity, interventions to tackle the problem are not straightforward. But it is still possible for GPs to take a population health approach.
So, how would they do that?
An example of a population health approach to improving primary care services could start with four basic strategic questions:
- where are we now?
- where do we want to be?
- how do we get there?
- how will we know when we get there?
To answer the first question, it is crucial to identify the prevalence of obesity in practice lists and to develop obesity/ overweight registers. Analysing these identified cohorts by age, ethnicity, deprivation, and co-morbidity is relatively easy.
An example of such an analysis is given below using data from the EMIS system at an anonymised innercity practice.
As the table shows, it allows a snapshot comparison between obese patients and the practice average. In addition, it shows the impact of obesity on overall health and the inequalities within the obese cohort.
Government funding was made available in 2020 for a directed locally enhanced service (DES) to improve access to Tier 2 services (community-based lifestyle services). This incentivised practices to better identify patients and facilitate their referral to community lifestyle services. However, it highlighted the underreporting of obesity in primary care, which reflects the international literature; reported prevalence in Australia was 22% and in the USA, 20%.
A new paradigm
The next question of ‘where do we want to be’ comes back to the evidence of interventions.
Weight loss imparts therapeutic advantages to arrest or reverse obesity-associated co-morbidities (see figure below).
As shown, most co-morbidities improve at an optimum weight loss of 15% of initial body weight. Nevertheless, the widely accepted 5% loss remains valid as an alternative to doing nothing. Therefore, the aim should be to help patients lose weight and keep it off.
Appreciating obesity as a chronic relapsing condition is a new paradigm in management. With such an understanding, the door opens to effective consultation and dialogue with our patients. It will give us time and permission to engage our patients, assess their readiness for change, and educate and guide them through weight management.
An overall approach to obesity management is advocated in the WHO European Regional Obesity Report 2022 (figure below)
The model puts GPs in the centre, with motivational interviewing being the first step in consulting on obesity. GPs would need to be able to engage sensitively in conversations around excess weight and weight management. The five As approach is a valuable tool for such conversations (see box).
Patients identified as motivated to change are then medically evaluated and signposted to engage with lifestyle services. It may be helpful to use a long-term condition model to follow up and empower these patients (who may also be living with multi-morbidity). But we have some miles to go before we achieve this paradigm shift.
The wider GP team is vital in patient support. Advanced health practitioners – pharmacists, nurses, physician assistants and social prescribers – have important roles in supporting patients to optimise their lifestyles to help with weight management.
Practices need resources to enhance the inclusivity of obese patients. For example, staff would need to be trained in communicating sensitively, and there are practical considerations too. These include ensuring waiting rooms are equipped with suitable seating and providing wide blood pressure monitoring cuffs in consulting rooms.
A needs assessment of practices – a key tool in a population health approach – would be required.
Partnership working
So, how can we achieve this in an overstretched health system?
The simple answer is that we can only if we try to do it with others. Partnership working is needed, now more than ever, to achieve a shared understanding and vision. That way, we can develop effective weight management services that are equitable and accessible, affordable, timely and relevant. Clear patient pathways are needed with proper incentives for achieving realistic population-level targets.
PCNs have inequalities directed enhanced service (DES) agreements that can be aligned with obesity management. There is the potential for double benefits if patient cohorts with obesity meet the criteria for achieving the PCN target of tackling inequalities. For example, they might live in deprived areas, come from BAME communities, have poor educational achievement and be unemployed or homeless. However, this approach needs a further detailed analysis of practice records to identify suitable patient cohorts.
Group consultations on lifestyle management can be helpful, efficient and foster peer support. These are relatively new to the UK health service landscape but have shown promising results. They are deemed cost-effective and liked by patients and healthcare workers in the context of chronic disease management, particularly diabetes.
The evidence for improved clinical outcomes is less clear and requires more research (1).
The Leadership Challenge
Clinical leadership is crucial for initiating the change needed.
For example, at present, medications (mainly the GLP receptor agonist – Liraglutide and, in the near future, Semaglutide) are offered to patients with strict criteria and only in a secondary care setting. Prescribing these medications in a primary care setting will have massive cost implications. Still, there needs to be an economic case for this to weigh the cost of prescribing against the enormous ongoing costs of managing long-term conditions like DM – where weight loss is known to lead to the reversal of the condition. Hypertension, NAFLD, and numerous others are also the direct consequences of obesity.
These economic evaluations are part and parcel of a population health approach, and they should include GP leaders with obesity management interest and expertise.
Aside from pharmacotherapy, there is a role for primary care using population interventions. However, positioning obesity on par with other long-term conditions is difficult when patient pathways are not adequately resourced. Nevertheless, the first step is recognising obesity as a long-term condition and initiating or scaling up advocacy for tackling the issue.
Primary care could set up and participate actively in partnerships for tackling obesity with other organisations, notably public health, secondary care, community services and patient advocates, as a minimum. It should be noted that the number of stakeholders in this agenda can grow massively, reflecting the complexity of factors involved.
Practices can identify patients living with obesity and keep accurate registers. They can analyse the health needs of these cohorts of patients to identify co-morbidities using the Edmonton obesity staging scale (see picture above).
They can refer patients appropriately to tier two services, such as community lifestyle support and tiers three and four in secondary care. These would include specialist weight management services and bariatric surgery. And, of course, practices can provide long-term follow-up.
Even at a micro level, individual champions can recognise, educate and fight weight-associated stigma.
It needs to be clear, though, that there is no expectation that individual GPs should shoulder these changes on their own. That is especially true in the current challenging environment with severe work pressures. Tackling obesity requires time, headspace and stamina. Hopefully, the issues in the health system will be resolved enough in the not-so-far future to enable this to happen.
The 5As approach to consulting on obesity
The RCGP advocates the 5As approach of the Canadian Obesity Guidelines in its online obesity learning hub. This is suitable as a framework for consulting with this patient and should be promoted widely among primary care professionals. It will achieve the following tasks:
- Ask permission to discuss weight and explore readiness for change
- Assess the root cause and obesity-related health risks
- Advise on health risks and management options
- Agree on health outcomes and behavioural management goals
- Assist in accessing appropriate resources and providers
Recommended reading on obesity management:
- RCGP Learning Hub – Obesity
- CKS NICE Obesity
- WHO European Regional Obesity Report 2022
- Canadian Adult Obesity Clinical Practice Guidelines
By Dr Ishraga Awad, MBBS MPH FFPH MRCGP Pg Award (Population Mental Health & Wellbeing), GP and Public Health Specialist (with interest in Lifestyle Medicine and Obesity Management); Dr Sarah Cuschieri MD, PhD (Public Health), MFPH (UK), MSc (Diabetes), Pg. Dip (Diabetes), Pg. Cert. (Epidemiology Public Health), MRSPH (UK); Dr Michelle A Miller BSc (Hons), PhD, MAcadMEd, FFPH, FBHS, FAHA, Associate Professor (Reader) of Biochemical Medicine, Sleep, Health and Society Programme Lead and Health Sciences Post Graduate Research Academic Lead at the University of Warwick, Division of Health Sciences Warwick Medical School; Claire Beynon, Dirprwy Gyfarwyddwr Iechyd Cyhoedd /Deputy Director of Public Health, Tîm Iechyd Cyhoeddus Lleol Caerdydd a’r Fro / Cardiff and Vale Local Public Health Team, Bwrdd Iechyd Prifysgol Caerdydd a’r Fro / Cardiff and Vale University Health Board, Ty Coedtir / Woodland House
References:
- Andrew Booth et al. What is the evidence for the effectiveness, appropriateness and feasibility of group clinics for patients with chronic conditions? A systematic review, Dec 2015
