Technical Paper 1:
Obesity in Australia: a need for urgent action
5. Strengthen, upskill and support primary healthcare and public health workforce to support people in making healthier choices
A systematic review published in 2009 of primary care physicians’ knowledge, attitudes, beliefs and practices regarding childhood obesity showed that while almost all physicians agreed on the necessity to treat childhood obesity, they perceived themselves to have a low self-efficacy regarding such treatment. They also experienced a negative feeling regarding obesity management. Although extensive heterogeneity in the assessment of childhood obesity between the different studies was observed, awareness of the importance of using BMI increased among physicians over the period of the review (1987–2007). Almost all of the identified studies noted that physicians recommended dietary advice, exercise or referral to a dietitian.
The authors concluded that the results of the review indicated a clear need for the education of primary care physicians to increase the uniformity of the assessment and to improve physicians’ self-efficacy in managing childhood obesity. They identified multidisciplinary treatment (including GPs, paediatricians and specialised dietitians) as a key component in addressing the growing obesity epidemic and cited the importance of primary care physicians in initiating, coordinating and participating in obesity prevention initiatives.
The management of overweight and obesity presents many challenges for primary healthcare providers. An article by Anderson in 2008 addressed six questions in an attempt to close the gap between primary care activities and public health goals to reduce overweight and obesity. The issues covered included:
- What is overweight and obesity?
- What is the health impact of overweight and obesity?
- Is individually directed advice effective in reducing overweight and obesity?
- Can we increase the involvement of primary care in reducing overweight and obesity?
- How can public health actions complement the role of primary care?
- How do we chose cost-effective interventions?
Systematic reviews and key texts were identified from literature searches to provide a narrative summary to respond to these questions. The author found there is a positive relationship between the level of BMI and a wide range of conditions, including cancers and cardiovascular diseases. There is evidence that individually directed advice can reduce overweight and obesity or its risk, and mixed evidence for the effectiveness of strategies in increasing the involvement of primary care in reducing overweight and obesity. There are many examples of public health actions that complement the role of primary care in reducing overweight and obesity. While overall cost-effective policy analyses per se for overweight and obesity were not identified in this review, the author reported that a combination of personal and non-personal interventions can be effective and cost-effective in reducing cardiovascular events.
The study concluded that the gap between primary care and public health in reducing overweight and obesity can be closed, but it requires sustained political support and investment.
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As gatekeepers to the health system, GPs are placed in an ideal position to manage obesity. Yet, very few consultations address weight management. Australian research published in 2008 explored reasons why patients are not engaging with their GP for weight management. It also examined patients’ perceptions of the GP’s role in managing their weight. Conducted in 2006, the study involved 367 17–64-year-olds recruited from three general practices in Melbourne. Participants completed a self-administered questionnaire in the waiting room. Questions included basic demographics, the role of the GP in weight management, the likelihood of the patient bringing up weight management with their GP and reasons why they would not, and their nominated ideal person to consult for weight management. Physical measurements to determine weight status were then completed.
Almost three-quarters (74%) of patients reported that they were not likely to bring up weight management when they visited their GP; negative reasons reported included time limitation on both the patient’s and doctor’s part, and the doctor lacking experience. The GP was the least likely person to tell a patient to lose weight after partner, family and friends. Of the 14% of participants who had been told by their GP to lose weight, 90% had cardiovascular obesity-related comorbidities. Participants cited GPs as fourth in the list of ideal people to manage weight. The authors concluded that patients do not have confidence in their GPs for weight management, preferring other health professionals who may lack evidence-based training. They also concluded that it appeared currently GPs target only those with obesity-related comorbidities.
The authors recommended further studies evaluating GPs’ opinions about weight management, and the development and implementation of effective strategies that can be implemented in primary care, including coordination of a team approach.
Further Australian research examined the prevalence and rate of management of childhood overweight and obesity in Australian general practice. A cross-sectional study was conducted among 3978 GPs, randomly selected using Medicare Australia claims, who recorded 42,515 encounters with 2–17-year-olds – including 12,925 sub-sampled encounters with self- or carer-reported height and weight collected. A total of 29.6% of sub-sampled children were classified as overweight (18.3%) or obese (11.4%). GPs managed overweight and obesity during 215 encounters, or once per 200 encounters with children aged 2–17 years, and once per 58 encounters with overweight or obese children.
The content of encounters in overweight and non-overweight children did not differ. Children who were managed for overweight or obesity presented with these conditions as reasons for the encounter significantly more often and were managed for more problems, particularly depression, than average per 100 encounters. Consultations for overweight or obesity were significantly longer than average. The authors concluded that while overweight and obesity are prevalent in children presenting to Australian general practice, GPs do not use most of the available opportunities to manage this problem.
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While a common policy response to the childhood obesity epidemic is to recommend that primary care physicians screen for and offer counselling to the overweight/obese, there is evidence to suggest this may not be the most effective approach. For example, an economic evaluation of a primary care trial – Live Eat and Play (LEAP) – to reduce weight gain in overweight/obese children was undertaken in Victoria in 2002–03. LEAP was a randomised controlled trial of a brief secondary prevention intervention delivered by family physicians and targeting overweight/mildly obese children aged 5–9 years. Primary care use was audited prospectively using medical records; parents reported family resource use by written questionnaire. Outcome measures were BMI and parent-reported physical activity and dietary habits in intervention compared with control children. The cost of LEAP per intervention family was $4094 greater than for control families, mainly due to increased family resources devoted to child physical activity. Total health sector costs were $873 per intervention family and $64 per control. At 15 months, intervention children did not differ significantly in adjusted BMI or daily physical activity scores compared with the control group, but dietary habits had improved.
The authors concluded that this brief intervention resulted in higher costs to families and the healthcare sector, which could have been devoted to other uses creating benefits to health and/or family wellbeing; this has implications for countries such as the United States, the United Kingdom and Australia, where current guidelines recommend routine surveillance and counselling for high child BMI in the primary care sector.