Rethinking primary care systems for obesity
Authors: Boyd Swinburn, Bruce Arroll
Journal: The Lancet (2016)

Paul Aveyard and colleagues, in The Lancet, provide optimistic news for the management of obesity in primary care.1Aveyard P Lewis A Tearne S et al.Screening and brief intervention for obesity in primary care: a parallel, two-arm, randomised trial.Lancet. 2016; (published online Oct 24.)http://dx.doi.org/10.1016/S0140-6736(16)31893-1Google Scholar In this parallel, two-arm, randomised trial of screening and a brief intervention for obesity in primary care, Aveyard and colleagues identified a net weight loss benefit at 12 months from a 30 s active intervention by primary care physicians. A striking feature of the study was that patients with obesity (body-mass index of at least 30 kg/m2 or at least 25 kg/m2 if of Asian ethnicity) were invited to participate with no assessment of their readiness to change, yet the majority (2263 [83%] of 2728 potentially eligible participants) were willing to do so, of whom 1882 individuals were eligible to enrol in the trial. 940 patients in the active intervention group were offered a specific appointment (made before leaving the clinic) to a weight management group (12 sessions of 1 h each, once per week) with follow-up support and advice, and 942 patients in the advice only (control) group were simply advised by the primary care doctor that their health would benefit from weight loss. At 12 months, mean weight change was 2·43 kg in the advice plus support group compared with 1·04 kg in the advice only group, giving an adjusted difference of 1·43 kg (95% CI 0·89–1·97). The number needed to treat to achieve a 5% weight loss (about 5 kg) at 12 months was 8·8, which is very good for a preventive intervention. By comparison, the number needed to treat for nicotine replacement therapy with respect to 12 month quit rate is about 152Green G Nicotine replacement therapy for smoking cessation.Am Fam Physician. 2015; 92 (24B): 24APubMed Google Scholar and exercise prescriptions for 12 month achievement of physical activity guidelines have a number needed to treat of about ten.3Elley CR Kerse N Arroll B Robinson E Effectiveness of counselling patients on physical activity in general practice: cluster randomised controlled trial.BMJ. 2003; 326: 793Crossref PubMed Google Scholar 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. A survey of family physicians in the USA found that, of ten chronic disorders, obesity treatment was regarded as less effective than all but treatment for drug addiction.4Foster GD Wadden TA Makris AP et al.Primary care physicians' attitudes about obesity and its treatment.Obes Res. 2003; 11: 1168-1177Crossref PubMed Scopus (498) Google Scholar This finding supports our experience with physicians who report how difficult it is for patients to lose weight and keep it off. Physicians might see the task as being too complex, lack confidence in giving nutrition advice,4Foster GD Wadden TA Makris AP et al.Primary care physicians' attitudes about obesity and its treatment.Obes Res. 2003; 11: 1168-1177Crossref PubMed Scopus (498) Google Scholar or have become disillusioned with the poor outcomes. Clinicians might also fear insulting patients by raising the issue of obesity, yet in this study only four (<1%) of patients said the interventions were inappropriate and unhelpful. Clinicians' own weight problems might also inhibit discussion, but Perri Klass5Klass P The elephant in the exam room.Health Aff (Millwood). 2010; 29: 554-557Crossref PubMed Scopus (1) Google Scholar suggests that health professionals must acknowledge their own weight struggles and "do the job effectively". Effective resources are available in the form of commercial weight loss courses, but cost could be a barrier.6Madigan CD Daley AJ Lewis AL Jolly K Aveyard P Which weight-loss programmes are as effective as Weight Watchers®?: non-inferiority analysis.Br J Gen Pract. 2014; 64: e128-e136Crossref PubMed Scopus (30) Google Scholar Long-term behaviour change is hard and failed attempts at weight loss are ubiquitous. For some patients, such as those with a history of weight cycling, it could be time to move away from the sisyphean task of pursuing weight loss goals and onto achieving other valued health goals.7Lillis J Kendra KE Acceptance and commitment therapy for weight control: model, evidence, and future directions.J Contextual Behav Sci. 2014; 3: 1-7Crossref PubMed Scopus (66) Google Scholar The efforts needed to yet again break out of the metabolic, physical, psychological, and environmental vicious cycles that trap them in the state of obesity8Swinburn B Egger G The runaway weight gain train: too many accelerators, not enough brakes.BMJ. 2004; 329: 736-739Crossref PubMed Scopus (145) Google Scholar, 9Fothergill E Guo J Howard L et al.Persistent metabolic adaptation 6 years after "The Biggest Loser" competition.Obesity. 2016; 24: 1612-1619Crossref PubMed Scopus (352) Google Scholar might be better directed at healthy eating and physical activity with no further weight gain. However, far from giving up on weight loss entirely, Aveyard and colleagues' results should trigger a rethink of the primary care approaches to obesity on two counts. First, the positive results of the 30 s active intervention signal a need for further such studies so that the evidence base for brief interventions for weight management matches that for quitting smoking,10Stead LF Buitrago D Preciado N Sanchez G Hartmann-Boyce J Lancaster T Physician advice for smoking cessation.Cochrane Database Syst Rev. 2013; 5 (CD000165)Google Scholar exercise prescriptions,3Elley CR Kerse N Arroll B Robinson E Effectiveness of counselling patients on physical activity in general practice: cluster randomised controlled trial.BMJ. 2003; 326: 793Crossref PubMed Google Scholar and alcohol problems.11Kaner EF Beyer F Dickinson HO et al.Effectiveness of brief alcohol interventions in primary care populations.Cochrane Database Syst Rev. 2007; 2 (CD004148)Google Scholar This brief intervention as part of a usual consultation capitalises on opportunities within the current systems of primary care practice. The second, bigger rethink is how to work on the systems for primary care to achieve both clinical and population outcomes. The so-called control group in this study was in fact an intervention itself over and above current practice. This control intervention involved physician training on how to discuss weight with patients, addressing of weight bias, weighing of all patients, discussion of weight within the consultation, giving brief advice, and provision of follow-up phone calls and weight measurements. These are all systems changes at a practice level and they resulted in a 12 month weight loss of about 1 kg. Far from being trivial, a 1 kg weight loss or even no weight gain applied at the population level could help to reduce the enormous burden that obesity places on health systems. Although mass, population-wide weight loss is not a plausible strategy, prevention of age-related weight gain in the adult population is. If primary care systems operated in line with the control condition in this study, they would contribute to progressively reducing adult obesity prevalence. A primary care system that makes weight a vital sign12Queensland Clincal SenateEvery k is not ok: putting the brakes on obesity. Meeting report. July 31, 2015. State of Queensland (Queensland Health), Brisbane2015Google Scholar by actively monitoring weight in all patients and communicating the benefits of normal growth trajectories for children and no age-related weight gain for adults would go a long way to fulfilling its population health potential to prevent the weight-related health problems that fill up its waiting rooms. We declare no competing interests. Screening and brief intervention for obesity in primary care: a parallel, two-arm, randomised trialA behaviourally-informed, very brief, physician-delivered opportunistic intervention is acceptable to patients and an effective way to reduce population mean weight. 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