Q&A: The advice PCPs should give to patients with overweight, obesity
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Key takeaways:
- PCPs often struggle addressing obesity because of a lack of knowledge and training.
- An intervention including exercise and a specific diet produced weight loss and can be implemented in primary care.
As the first point of contact for many patients, it is important for primary care physicians to have strategies that will help treat and manage overweight and obesity, according to experts.
However, PCPs commonly struggle with addressing the common condition, Morten Dag Nilsen, MD, a general practitioner specialist with the University of Oslo in Norway, told Healio. Nilsen and colleagues conducted a study including 23 physicians and 210 patients to evaluate if a simple tool with a specific diet and activity plan was feasible and effective.
“The plan consists of a relatively significant change in diet with a substantial reduction in calories in the first 3 weeks because a considerable initial weight reduction can lead to better long-term results,” they wrote.
In the first 4 weeks, participants in the intervention ate at least four meals a day of salad and vegetables, eggs, shellfish, fish and meat but could not drink alcohol or eat pasta, rice, bread, potatoes, fruit, cereal products, nuts and dairy products. They were also instructed to cycle or walk for 20 to 30 minutes each day, which could be divided into several sessions.
After 4 weeks, the diet plan became more varied and followed the Norwegian National Council for Nutrition’s current recommendations. For the following 11 months, the participants walked or cycled for 30 to 40 minutes each day and ate oatmeal with a few berries or nuts or a slice of bread with fish, lean cold cuts or low-fat cheese. They then ate three to four tablespoons of low-fat Quark or cottage cheese and a small portion of nuts or fruit for a snack. For lunch, they ate salads with eggs, tuna fish or chicken. They then ate fish or meat and vegetables or salad with a bit of rice or pasta for dinner. For supper, they ate two crispbreads or a slice of bread with fish, lean cold cuts or low-fat cheese.
Healio spoke with Nilsen to learn more about the study and its clinical implications for PCPs.
Healio: Can you discuss the importance of addressing overweight and obesity in primary care? Why did you decide to research this subject?
Nilsen: Research has shown that physicians in primary care often avoid talking about overweight and obesity with their patients. The main reasons they give are not having sufficient training, education and knowledge in the field and that they lack something specific to offer their patients. Fear of offending is also a reason why PCPs avoid addressing overweight and obesity.
Studies show that a majority of patients with overweight and obesity want their doctor to discuss this issue with them. I, therefore, believe it is important to discuss overweight and obesity with our patients. However, the way this is conducted is of great importance. As we pointed out in the article, a negative attitude toward people with overweight and obesity is widespread — also among health care personnel, including physicians. Many have the opinion that this is purely a matter of willpower. Not only will such an attitude prevent patients from getting help, but it can also worsen their state of health, both physically and mentally, and lead to weight gain.
I have worked as a PCP for a long time. During the first years, I gave oral advice to the patients to eat often and little, avoid fat and sugar and eat lean products, lots of vegetables and some fruit. It didn't help. I also tried to follow the guidelines and suggestions I received from the Norwegian health authorities and from the specialist health services regarding follow-up and measures, but these were not adapted to my everyday work situation, and I simply could not use them. I found little research on the treatment of patients with overweight and obesity with suggestions that could be implemented in primary care.
For me, things changed when I started to become much more specific. I gave both oral and written advice that was detailed and I followed up with the patients closely — especially in the initial phase. The results were much more satisfying, and I have since used this approach. After a while, I started wondering if other PCPs could get equal results by using my approach. I also found — and find — that patients with overweight and obesity, in many cases, do not receive the help they need, and hoped that my approach could be used to improve this situation to some extent. As I mentioned, I also found little research with specific measures that I was able to use. Those were the main reasons why I decided to try to carry out a study.
Healio: Will you briefly describe your intervention, findings and their clinical implications?
Nilsen: In the intervention, the patients started with a restrictive diet to use for the first 4 weeks. They then switched to a more normal diet. Research has shown that significant initial weight reduction can produce better long-term results. A 5% weight reduction provides health benefits, and 45% of the patients in the intervention group in our study still had at least a 5% weight reduction after 2 years. Also, 24.2% had a weight reduction of at least 10% after 2 years.
The method is simple and easy to use and can therefore fit well in a busy work situation. I think it can represent a tool to help patients with overweight and obesity in general practice.
Healio: How can some of the difficulties that come with PCPs treating overweight and obesity be overcome?
Nilsen: I allow myself to recommend to my colleagues in the U.S. to learn as much as possible about overweight and obesity and to use an approach that is as specific as possible. A lasting change in lifestyle and diet is what we try to help our patients achieve, but we will not be able to do that if we are prejudiced against people with overweight and obesity. Changing any negative attitudes of your own is crucial. Be curious and interested. Try to get the patients and yourself to commit to working together over time. Be supportive and try to find and agree upon realistic goals. An approach where the main focus is the patient's health — not the weight — can make it easier to address the topic and achieve results.
Healio: What is the take-home message for PCPs?
Nilsen: Sometimes it can feel overwhelming trying to help patients with overweight and obesity to lose weight, but it can be done. Our study showed that almost 45% of the patients in the intervention group lost at least 5% of their weight after 2 years, giving them health benefits. My advice would be to present the patients with a specific plan and to commit yourselves to follow up with them over a long period of time. Focus on the patients’ health, and try to motivate and be supportive. In my experience, patients with overweight and obesity are generally very positive, interested and easy to work with.
Healio: Is there anything else you would like to add?
Nilsen: The primary health service is organized in different ways in different countries, but we as PCPs often face many of the same problems in our line of work, regardless of where in the world we practice. What I have missed in much of the research I have found about treatment of patients with overweight and obesity are specific suggestions or recommendations that I am able to use in my everyday work situation. It is in primary care that most patients with overweight and obesity first get in touch with the health care system, so it is essential to develop measures and methods that can be used here. They must be easy to implement, not too time-consuming and produce results. I hope that our article, which contains specific suggestions, can be of help to my American colleagues and their patients.