Issue 23 / 18 June 2012

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

9 thoughts on “Stewart Truswell: Weighty barriers

  1. JD says:

    “around 35% of patients who attended follow-up for 12 months had maintained a weight loss of 5% or more”.
    When are we going to learn that weight loss programs based on diet and exercise are basically ineffective for the vast majority of obese patients; 12 months is a very short period in the life of an obese individual – all the studies show that with longer follow-up the failure rate increases. We need more effective therapies.
    The last sentence or the article is probably a truer expression of therapeutic reality.

  2. Guy says:

    This article neglects the issue of why our society is becoming obese in the first place.
    Obesity has exploded in the past 30 years. So what has changed?
    David Kessler, a former head of the FDA and dean of Yale and UCSF medical schools addresses this question in his book, The End of Overeating. He states that the research by the US National Institutes of Health has established that virtually the entire obesity epidemic in the US over the past 30 years can be traced back to excessive consumption of what he terms hyperpalatable foods, which are foods unnaturally high in fat, sugar and salt and which are in fact designed to promote overconsumption.
    In other words, our society is becoming obese because we are eating too much junk food. This can be a powerful insight in weight loss promotion.

  3. docsteve says:

    Guy states an important truth, but it is no less important to acknowledge the role of ‘labor saving devices’ in our obesidemic. Cars, TVs, computers, mirowave ovens, clothes washers and dryers, apartment living …. and many more contribute to the reduced body movement required to get along in modern life. We once (not so long ago) had to walk to a market, haggle over fresh foods and carry what we bought home again. Our pastimes included walking in many forms (to the beach, to the footie game, to the bushwalk …) and gardening to provide our minimum needs (fresh veges), not just to look pretty (‘landscaping’).
    So it is very true that we access high energy foods which taste ‘terrific’ (if you like that sort of thing), AND we have advertising telling us to eat more all the time, but we also DO less.
    BOTH of these need to be addressed, and the politicians have power to change things (bike paths?) which we doctors can only talk about ….

  4. Guy says:

    While physical activity is useful for weight loss, Kessler argues in his book that research by the NIH has shown that physical activity levels have not changed significantly in the US in 30 years but that overconsumption of foods high in fat sugar and salt has increased continuously over the period and can be directly correlated through regression analysis to the rise of obesity.
    We have internal mechanisms which link exercise to appetite.
    We know from convict ration records that while the early Australian convicts did much more exercise than present day Australians, they ate 2500kJ (600kCal) more per day to compensate for it.
    See Egger GJ, Vogels N, Westerterp KR. Estimating historical changes in physical activity levels. Med J Aust. 2001 Dec 3-17;175(11-12):635-6.

  5. JD says:

    Guy et al, from my reading of the research, with this sort of work, often there has not been much in the way of detailed measurement done. Rather, much of it has been broad-based epidemiological work with lots of calculations leading to associations. But association is not enough to show causation, especially when the associations are made at a broad community level without looking at the affected individuals in detail. There are many individuals who don’t get fat and who don’t have to work at avoiding it. So, there are some fundamental questions that need answering, rather than pointing to a phenomenon (overeating energy dense food) and saying that is the answer. When more detailed research has been done looking at diet, the conclusions are not what would be expected: fat does not make you fat; energy density does not seem to be important. See this interesting blog that looks at some of the relevant research:

  6. Guy says:

    There is a difference between simple energy density and so-called hyperpalatability. Pure fat or pure sugar, for example, are highly energy dense, but nobody consumes them in that form.
    What Kessler describes in his book is an industry which designs foods which are specifically intended to promote overconsumption. This requires much experimentation and taste testing and relies on the way in which combinations of fat, sugar and salt stimulate opiate and serotonin receptors in the brain in self reinforcing ways (as shown by MRI studies) in a manner similar to addictive drugs like cocaine and morphine.

  7. JD says:

    Guy, it is drawing a very long-bow to say that certain foods are as addictive as cocaine and morphine just because they light up certain parts of brain on fMRI. There are many things that are enjoyable that probably do the same thing without being “addictive”. Hyperpalatable foods are energy dense (see your own description). However, what you are describing is basically an unproven hypothesis. Studies that look at what people eat and their weights don’t support this hypothesis. It would be a mistake to focus our energies on the junk food industry, if they weren’t the cause of the obesity epidemic.

  8. Guy says:

    The argument by Kessler that junk food is the cause of the US obesity epidemic is based upon two things (1) the increase in total calories consumed and (2) the corresponding increase in sales of junk food over the same period. The NIH tracks these things closely.
    Nobody has said that junk food is as addictive as cocaine and morphine but merely that there are similar mechanisms of addiction involved with similar circuits and opioid and serotonin receptors.
    Kessler describes the neurophysiology studies in rats and humans which demonstrate the circuitry involved.
    He also describes the steps in which new foods are developed using known layers of ingredients which reinforce one another. This is a whole branch of food science.
    Because hyperpalatable food is energy dense does not mean that all energy dense food is hyperpalatable. This is a simple logical fallacy like saying all four legged animals are cats because cats have four legs.

  9. JD says:

    Guy, the logical fallacy is with the postulate that junk food is the cause of “overconsumption”. This is by no means proven. There is really no measured data on who is “consuming” the “increase in total calories” – it assumed to be obese people. In effect Kessler is saying that if there were no junk food, that there would be no obesity epidemic. What if the drive to “overconsumption” (if it indeed occurs) was something else (say epigenetic factors), and hyperpalatable food just happened to be there (an innocent bystander).

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