Prompting lifestyle interventions to promote weight loss is safe, effective and patient-centred: Yes

Obesity is a health risk

New Zealand has the third highest obesity rates in the world, and these rates are projected to increase.¹ Importantly, the obesity epidemic results in at least 3200 lives lost per year² and is now the biggest cause of preventable death after smoking. Obesity in adults is associated with type 2 diabetes, ischaemic heart disease, stroke, many cancers including breast, bowel and endometrial cancer, osteoarthritis, sleep apnoea and reproductive abnormalities such as Polycystic Ovary Syndrome.³ It also impacts on people’s social and psychological well-being. The cost of obesity has been estimated to be between $4 and $9 billion per year.⁴

Weight loss has been shown in both trials and observational studies to improve health risk factors such as high blood pressure, hyperlipdaemia and hyperglycaemia.^5–7 It can also improve patient quality of life⁸ and has been shown to reduce the risk of type 2 diabetes⁹ and death from cardiovascular disease and cancer.^7,10 The impact of being overweight or obese varies tremendously between individuals. In some having a BMI in the overweight or obese range may have little or no relationship with physical or psychological symptoms, cause no functional limitations or be associated with other risk factors such as hypertension or insulin resistance. On the other hand in some patients the reverse may be true.¹¹ Weight management requires a patient-centred approach that addresses the patient’s individual risk factors and symptoms. Some patients may want to lose weight, not because of perceived health risks but due to psychosocial pressures related to body image. This can lead many patients to find their own weight loss solutions that may be ineffective or even harmful.¹² It also needs to be acknowledged that Māori and Pacifica people face added challenges with weight management due to socioeconomic and environmental pressures.

For those patients whose weight is a threat to their well-being general practice is well placed to be able to offer safe and effective interventions that are appropriately tailored to patient’s needs. The longitudinal nature of the general practice relationship and the multidisciplinary primary care team structure mean that patients can be monitored over time and any potential adverse effects can be dealt with. While BMI is routinely used in general practice as a measure of health risk, eg in CVD risk assessment tools, on its own it is an imprecise tool. Using more patient-centred approaches such as the Edmonton Obesity Staging System¹¹ or the SECURED model (Severity, Expected prognosis, Comorbidities, Urgency of control, Risk of complications, Environmental factors and Disability)¹³ allow health professionals and patients to take a more holistic approach to the assessment and management of weight.

Weight loss is difficult to achieve

There are a number of strategies available that can help reduce the health impacts of obesity. These can include population-based strategies such as the use of sugar taxes, GST off fruit and vegetables and the use of public sector planning to encourage exercise and reduce sedentary behaviours. There is also a role for the individual patient-centred approach to weight management which can range from intensive behavioural and lifestyle modifications, to the use of medication and in life threatening cases, bariatric surgery. Lifestyle modification in General Practice has been shown to be effective¹⁴ although not as successful as more intensive programmes delivered in trials such as the Diabetes Prevention Studies.⁹ A meta-analysis of randomised controlled trials (RCTs) found that diet and exercise programmes combined were clearly superior to diet programmes alone or exercise programmes alone.⁷ However, regardless of the programme offered, there are usually a group of patients who do not adhere to the diet and exercise regimen and either do not lose weight or they may even gain additional weight.¹⁵ Programme adherence is most likely with supervised attendance programmes and interventions that offer social support.¹⁶

Safety

The rates of adverse events in behavioural weight loss programmes are rarely reported. Perceived risks can include rapid weight loss, yoyo weight loss, and adverse psycho-social effects. It is therefore important to monitor those who are adhering to a prescribed weight loss programme. However, it should be noted that there is little evidence of any increased risk due to weight loss interventions associated with weight cycling.¹⁷ As noted behavioural weight loss programmes if carried out appropriately are effective. The ethical challenge is whether to prompt patients about their weight. Doctors would be considered negligent if they found a patient had hypertension or hyperlipidaemia that increased the patients risk and yet did not communicate the risks and treatment options to their patients. In the same way it can be argued that in those patients where excessive/unhealthy weight appears to be present, that an appropriate assessment should be made of the patient’s risk, and if it is apparent that their weight is likely to impact negatively that the doctor has an obligation to raise this with their patient.

Implementation challenges

The biggest barrier for general practice is that the resources need to be available to be able to offer an effective and patient-centred intervention. The Ministry of Health Guidelines¹⁸ suggest this should include time to establish long-term trust relationships with patients, regular reviews of weight management plans and the use of relevant support services to address identified barriers. To ensure equity, general practitioners should develop collaborative partnerships with Māori health providers, Whānau Ora providers and other community-based organisations that provide weight management education and services.¹⁸ In the current primary care environment the time and resources needed are lacking. As a collective it would seem that the solution is not to ignore the risk of excessive weight in our patients but rather to be raising this issue with the funding arm of Te Whatu Ora that urgent intervention is required. Sapere estimated that for each dollar spent tackling obesity the country would gain $5.6 in economic benefit. Funding is urgently needed so that primary care practitioners can feel confident in prompting their patients who have unhealthy weight that they can be offered a safe, effective and patient-centred intervention.

Conflicts of interest

Author declares no conflicts of interest.

Declaration of funding

No specific funding was received.