For many reasons, general practice is ideally suited to support weight management. It is the first port of call for patients, and often the gateway to other services. In England, 28.3 million GP appointments were booked for September 2022, the majority (68.2%) face-to-face (BMA, 2022). Tiered obesity care pathways in the UK rely on the active involvement of community-based healthcare practitioners (Wilding, 2018). Tier 1, commissioned by local authorities, has a universal prevention focus, promoting healthy eating, physical activity and behaviour change. It is delivered in the primary care setting by GPs, and school, practice and community nurses, among others (Obesity Empowerment Network (OEN), 2022). Tier 2, also commissioned by local authorities, provides lifestyle weight management services, referred into by primary care staff (OEN, 2022). Increasingly, community care services delivered locally (eg by community podiatrists, physiotherapists and speech and language therapists, as well as district and school nurses) help to reduce pressure on secondary care and embed services in the community. An estimated 100 million patient contacts are made by community care services annually, with important benefits for patients including local health promotion and management of long-term conditions (Charles, 2019). General practice can reach people in their local areas, is more likely to see patients regularly and, therefore, has the potential to establish relationships which support healthful behaviour change.
What is the need to intervene?
Provision of weight management services is criticised as patchy and inconsistent (Royal College of Physicians, 2015; Hazlehurst et al, 2020), despite well-evidenced need. Excess weight continues to affect a high proportion of the UK population. Current estimates suggest 25.3% of adults (≥18 years) and 23.5% of children (10-11 years) in England are living with obesity (NHS Digital, 2022; Office for Health Improvement and Disparities (OHID), 2022), albeit based on limited data due to the COVID-19 pandemic. Lockdowns introduced to reduce spread of the COVID-19 virus had a marked effect on eating and activity behaviours.
A review of the impact of the 2020 lockdowns in several countries including the UK highlighted both negative and positive impacts on weight-related behaviours (Bennett et al, 2021). Negative effects included increased consumption of higher fat, salt and sugar foods and reduced activity levels, while positive changes included increased home cooking and eating fresh products, and reduced processed food and alcohol consumption (Bennett et al, 2021). Longitudinal surveys of weight change in UK adults at three time points in the pandemic demonstrated substantial fluctuations in weight, with considerable variation between individuals, suggesting that, for some, a lasting impact of the pandemic on weight is possible (Dicken et al, 2021). Others have shown most pronounced negative effects of the COVID-19 pandemic on diet and activity behaviours in those with a higher body mass index (BMI) (Robinson et al, 2021).
The extent to which changes in weight and weight-related behaviours due to the pandemic will be maintained is unclear. Although the proportion of children living with obesity in England increased by 4.5% in both 4-5 and 10-11 year olds in 2020/21 to 14.4% and 25.5% (NHS Digital, 2021), it subsequently fell to 10.4% and 23.5%, respectively (NHS Digital, 2022). The most recent Health Survey for England was pre-pandemic. It found excess weight prevalence in adults of 68.2% in men and 60.4% in women, with obesity prevalence of 27.0% and 29.1%, respectively (NHS Digital, 2020). Prevalence was higher in men than women, increased with age (peaking in those aged 65-74 years), and was higher in deprived groups, those with disability, low educational attainment and highest in Black, followed by White, ethnic groups (Baker, (2021) The impact of the pandemic on obesity remains unclear (PHE, 2021a).
‘Pandemic-related negative changes to body weight, activity and eating behaviours occurred against an already problematic background
An already problematic situation
Pandemic-related negative changes to body weight, activity and eating behaviours occurred against an already problematic background. Activity levels in both adults and children prior to the pandemic were lower than recommended, and the pandemic and lockdowns reduced this further. Between November 2020 and 2021, 61.4% of the adult population reported themselves to be active, achieving 150+ mins of activity per week (Sport England, 2022) This was a fall from pre-pandemic activity levels (63.3% in November 2018/19), and multiple surveys suggest that more than a third of adults do not achieve the recommendations of the Chief Medical Officer (Department of Health and Social Care, 2019; Sport England, 2022).
Annual dietary intake surveys continue to show suboptimal intakes of fruit, vegetables and fibre, while intakes of free sugar, total fat and saturated fat remain higher than recommended, although free sugar intakes are falling (PHE, 2021b). Poor diets contribute to global ill-health, especially non-communicable diseases (NCDs) (GBD 2017 Diet Collaborators, 2019), and excess weight is itself also a risk factor for NCDs (World Health Organization (WHO), 2021). The WHO (2021) identifies diet as one of four modifiable risk factors which drive NCD risk, the others being low activity, excess alcohol and smoking. Excess weight is a well known contributor to risk of cardiovascular disease, type 2 diabetes, some cancers and hypertension (Prospective Studies Collaboration, 2009; Fruh, 2017; OHID, 2022).
More recently, COVID-19 has highlighted the impact of excess weight on population health and wellbeing (Tartof et al, 2020; Williamson et al, 2020; Public Health England, 2020; World Obesity, 2021; Gao et al, 2021; Katz, 2021). Among Organisation for Economic Co-operation and Development (OECD) countries, obesity prevalence in the UK is 10th highest (OECD Health Statistics, 2021). The need for change to address overweight and obesity effectively is clear. What is less clear is how to bring this about and how general practice fits into this.
Barriers to addressing obesity in primary care
In the UK, clinical guidelines identify primary care as key to identifying and monitoring excess weight, providing weight management support and/or referring to specialist weight management services (National Institute for Health and Care Excellence (NICE), 2014). In addition, general practice is valued as a first point of contact, ensuring continuity of care and support, enabling regular follow-up and management of co-morbidities (NICE, 2014). Despite this, recording patient weight is not routine in UK practice. Evaluation of 5 million electronic patient records showed that only a third of patients had weight recorded each year, with re-weighing on average every 2 years. Weighing was more common in females with raised BMI and those with comorbidities, and incentive payments appeared to increase weight recording (Nicholson et al, 2019).
Despite national guidance, obesity may be viewed as the responsibility of local commissioners rather than medical practitioners (Gunther et al, 2012), particularly if weight is not the presenting concern, making healthcare practitioners reluctant to raise the subject (Glenister et al, 2017; Mazza et al, 2019). Ambivalence in relation to the role of clinicians in weight management has been highlighted (Blackburn et al, 2015), with some believing that it is only their responsibility when weight impacts directly on health (McHale et al, 2020).
Surveys of general practice staff and/or patient views in Australia (Forgione et al, 2018; Mazza et al, 2019), New Zealand (Norman et al, 2022), Scotland (McHale et al, 2020) and the UK (Gunther et al, 2012) identified broadly similar issues in relation to weight management in primary care, despite differences in geography and healthcare structure. Patient barriers included weight stigma and previous negative experience, increasing their reluctance to raise the issue of weight with their healthcare practitioner (Gunther et al, 2012). Weight stigma is common in healthcare (Puhl et al, 2021a; 2021b), with the condition frequently ascribed to greed or laziness (Sikorski et al, 2011). Unsurprisingly, this can result in patient reluctance to seek medical help (Bidstrup et al, 2022).
Weight-related bias, both explicit and implicit, has been demonstrated in nurses, doctors, dietitians and physiotherapists (Lawrence et al, 2021). Assumptions about eating and activity behaviours may be made, with the topic of weight either avoided or discussed unhelpfully (Alberga et al, 2019). Weight bias increases the risk of disordered eating and further weight gain in those living with overweight or obesity, and stigmatising conversations about weight negatively impact on health motivation and compliance (Hayward et al, 2020), which may further reinforce negative views about patient motivation to lose weight (Glenister et al, 2017; McHale et al, 2020). In some cases, patients did not themselves recognise their excess weight as problematic (McHale et al, 2020). Since staff found it easier to raise the issue of weight in a neutral, non-discriminatory way by linking it to other patient health issues (Mazza et al, 2019; Norman et al, 2022), this resulted in apprehension about how to bring up the topic without causing offense or distress (McHale et al, 2020).
In a UK study, concerns about negative patient reactions to the subject of weight constrained GPs and practice nurses from broaching the subject (Michie, 2007). Trust was identified as key by both patients and healthcare practitioners (Gunther et al, 2012), and worries about harming relationships with their patients were commonly expressed (Blackburn et al, 2015; Blackburn and Stathi, 2019; Mazza et al, 2019; McHale et al, 2020). While recognising that discussions needed to be careful, healthcare practitioners did not always feel they had the counselling skills required, were not confident that discussing weight with patients would be effective, or that they knew the most appropriate language to use (Glenister et al, 2017). Lack of time to discuss weight was a major staff concern (Gunther et al, 2012; Glenister et al, 2017; Mazza et al, 2019; Norman et al, 2022).
Other staff barriers included lack of knowledge of weight management services and inadequate availability of suitable local services to refer into (Gunther et al, 2012; Mazza et al, 2019). Concern about the effectiveness of weight management services was expressed (Mazza et al, 2019). There was a suggestion that services referred into by primary care should update them with outcomes, to build confidence and encourage further referrals (Gunther et al, 2012).
In addition, staff failure to recognise obesity as a medical issue made them reluctant to take responsibility for dealing with it (Gunther et al, 2012; Blackburn et al, 2015). The Royal College of Nursing (2022) recognises obesity as central to almost every area of nursing practice, suggesting that nurses have a vital role to play in supporting those living with excess weight. Some studies suggest that in patients without co-morbidities, obesity may be viewed by healthcare practitioners as non-medical (Glenister et al, 2017); therefore, not the responsibility of primary care (Dewhurst et al, 2017). Obesity is classed as a disease in the USA, Canada and Portugal among others, but is not currently classed as such in the UK (Lancet Diabetes and Endocrinology, 2017). It is argued that recognition of obesity as a chronic, relapsing, recurrent disease (Bray et al, 2017), would enable a move from an individual blame perspective to one in which weight management is prioritised, enabling the development of more effective pathways in primary care (Jastreboff et al, 2019). Multiple other barriers have been highlighted, including inflexibility of referral criteria, funding limitations (Parretti and Chowhan, 2021) and lack of knowledge of obesity guidelines (Mazza et al, 2019).
Healthcare staff's own weight was also discussed (Blackburn et al, 2015; Mazza et al, 2019). The view that staff themselves living with excess weight would be able to empathise and relate to patients struggling with weight management, enabling sensitive conversations, was expressed. Conversely, others viewed excess weight of healthcare staff as a potential negative factor, since patients might be less inclined to listen to their weight management advice.
How can barriers in primary care be overcome?
An algorithm to guide primary care staff has been developed, following a 5As strategy based on that advocated in Canada (Wharton et al, 2020). The 5As are (Tahrani et al, 2020):
- Ask (permission to discuss the issue in a respectful non-stigmatising way);
- Assess (including co-morbidities, causes and barriers to treatment);
- Advise (treatment options including diet and physical activity, plus medication and possible referral to specialist services);
- Agree (on the treatment and treatment goals);
- Assist (regular follow-ups and encouragement).
Implicit in this is knowledge of what services are available locally. Sensitive language in relation to weight is advocated, both to reduce stigma and to facilitate helpful discussions, and several resources are available to help with this (see Box 1). The use of ‘People First’ language (ie ‘people with obesity’ rather than ‘obese people’), is particularly important to reduce weight-related bias (Palad and Stanford, 2018), while neutral, indirect and open-ended questions help facilitate discussions (Gray et al, 2018; Norman et al, 2022). Guidance on how to address obesity in primary care has been developed, to use alongside the algorithm (Parretti and Chowhan, 2021). The practice environment is important, since that sets the scene in terms of helping patients feel welcomed and accepted. Having equipment (eg blood pressure cuffs) in a variety of sizes (NICE, 2014; PHE, 2017), ensuring that any written communications include People First language and using non-stigmatising images of those living with overweight and obesity (see Box 2), are all aspects of the local environment that should be checked.
Box 1.Resources to support sensitive conversations about weight
- National Obesity Forum. Raising the issue. http://www.nationalobesityforum.org.uk/images/stories/PDF_training_resource/in-depth-raising-the-issue.pdf
- Public Health England. Let's Talk About Weight: A step-by-step guide to brief interventions with adults for health and care professionals. 2017. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/737903/weight_management_toolkit_Let_s_talk_about_weight.pdf
- Royal College of Physicians. Ten Top Tips. Raising the topic of overweight. https://tinyurl.com/4n48wjsw
Box 2.Resources for non-discriminatory images of people living with overweight and obesity
- World Obesity Image Bank. https://www.worldobesity.org/resources/image-bank
Primary care staff valued having national guidance embedded into practice procedures (Gunther et al, 2012). Therefore, auditing the extent to which this is currently the case locally may be helpful in highlighting actions which should be taken. Ensuring that staff are appropriately trained has also been emphasised (Segal et al, 2008), and this should be included in any audit of whether and how general practice is implementing national weight management guidance. Given that the consistency of weight management services is mixed (Royal College of Physicians, 2015; Jackson Leach et al, 2020), advocacy for better local service provision should be considered.
Conclusion
General practice plays an essential role in weight management, irrespective of whether weight is the presenting concern or not. Engaging respectfully with patients by using neutral language in a supportive environment is key. Practitioners’ own weight may be a positive or negative factor, but trust between patients and practitioners is considered vital by both. Despite ambivalence of general practitioners in relation to the role of primary care in weight management, national guidance identifies it as fundamental to the identification, management and ongoing support of those trying to manage their weight.
Key points
- Primary care, including general practice, has an essential role in weight management
- There are significant barriers to supporting patients with weight management in primary care and general practice identified by both patients and healthcare staff
- Knowledge of local care pathways and services by healthcare practitioners is important
CPD reflective practice
- How comfortable are you discussing weight with your patients?
- Reflect on a recent consultation where a patient has been struggling with their weight. Do you feel you tackled this appropriately? Why or why not?
- Are you aware of the local care pathways in your area? Where could you find more information?