Improving Obesity Prevention and Management in Primary Care in Canada

Describing the views of Canadian post-secondary students in health-related disciplines on the recognition of obesity as a chronic disease

OBJECTIVE

This cross-sectional study examined students' perspectives on the ramifications of obesity being recognized as a chronic disease in Canada.

PARTICIPANTS

Undergraduate and graduate students (n = 150) in health-related programs at a major Canadian university.

METHODS

An online survey featured open-ended questions to capture student perspectives on recognizing obesity as a disease. Data were evaluated using content analysis methods.

RESULTS

Positive themes identified included: (a) treatment accessibility; (b) improved healthcare provider attitudes; (c) de-stigmatization of obesity; (d) promotion of health behaviors; and (e) greater research/funding. Negative themes included potential: (a) healthcare system burdens; (b) perpetuation of obesity stigma; (c) medicalization of obesity; and (d) de-emphasis on modifiable risk factors as contributing to obesity.

CONCLUSIONS

There is a need to increase students' understanding of the multifaceted nature of obesity and the prevention of obesity-related stigma within healthcare. Findings may inform post-secondary health curricula and obesity initiatives.

Attitudes and knowledge about weight management among primary care physicians in Israel: a cross-sectional study

BACKGROUND

The prevalence of obesity has been increasing worldwide and is associated with increased risk of morbidity and mortality. Weight management can reduce the risk of complications and improve the quality of life of patients with obesity. This study explored primary care physicians' (PCPs') attitudes and knowledge about weight management.

METHODS

An anonymous questionnaire was distributed to 400 PCPs between 2020 and 2021. The survey included questions on treatment approaches (pharmaceutical and surgical) and items regarding the respondents' demographic characteristics. We compared PCPs with low or high proactivity toward weight management. We explored attitudes and knowledge with the chi-square test for categorical variables or the Mann-Whitney test for continuous variables.

RESULTS

A total of 145 PCPs answered our survey (a response rate of 36.25%). More than half (53.8%) of the respondents showed low proactivity toward weight management in their practice. Proactive respondents were more likely to believe that pharmaceutical treatment effectively reduces weight and offered medical and surgical treatment options more frequently to their patients. Lack of knowledge was the most predominant reason for PCPs avoiding offering treatment to their patients, especially in less proactive PCPs (33.3% vs. 5.3%, p-value < 0.001). When comparing different pharmaceutical options, 46.6% of PCPs report they tend to prescribe liraglutide to their patients compared with only 11% who prescribe orlistat and 10.3% who prescribe phentermine (p-value < 0.001).

CONCLUSIONS

Many PCPs still do not actively provide obesity treatment despite improved awareness and therapeutic options. PCPs' proactivity and attitudes are vital to this effort.

Obesity management in primary care: systematic review exploring the influence of therapeutic alliance

PURPOSE

To identify the influence of the therapeutic alliance on the effectiveness of obesity interventions delivered in primary care.

METHOD

Systematic review of randomized controlled trials of primary care interventions for adult patients living with obesity. Comprehensive search strategy using the terms 'obesity', 'primary care' and 'intervention' of seven databases from 1 January 1998 to March 2018. Primary outcome was difference in weight loss in interventions where a therapeutic alliance was present.

RESULTS

From 10 636 studies, 11 (3955 patients) were eligible. Only one study had interventions that reported all aspects of therapeutic alliance, including bond, goals and tasks. Meta-analysis was not included due to high statistical heterogeneity and low numbers of trials; as per our protocol, we proceeded to narrative synthesis. Some interventions included the regular primary care practitioner in management; very few included collaborative goal setting and most used prescriptive protocols to direct care.

CONCLUSIONS

We were surprised that so few trials reported the inclusion of elements of the therapeutic alliance when relational aspects of primary care are critical for effectiveness. Interventions could be developed to maximize therapeutic relationships and research reports should describe interventions comprehensively.

SYSTEMATIC REVIEW REGISTRATION NUMBER

CRD42018091338 in PROSPERO (International prospective register of systematic reviews).

Feasibility of identifying and describing the burden of early-onset metabolic syndrome in primary care electronic medical record data: a cross-sectional analysis

BACKGROUND

The prevalence of metabolic syndrome is growing worldwide, yet remains underinvestigated in Canadian young adults. We sought to explore the use of a harmonized case definition specific to early-onset metabolic syndrome and determine its feasibility in assessing the prevalence of metabolic syndrome among electronic medical record (EMR) data of young adults in Northern Alberta.

METHODS

We conducted a cross-sectional study using a sample of EMR data from young adult patients aged 18-40 years and residing in Northern Alberta, who had an encounter with a participating primary care clinic between June 29, 2015, and June 29, 2018. Physical examination, laboratory investigation and disease diagnosis data were collected. A case definition and algorithm were developed to assess the feasibility of identifying metabolic syndrome, including measures for body mass index (BMI), blood pressure (BP), dysglycemia, hypertriglyceridemia, high-density lipoprotein cholesterol, diabetes and hypertension.

RESULTS

Among 15 766 young adults, the case definition suggested the prevalence of metabolic syndrome was 4.4%, 95% confidence interval (CI) 4.1%-4.7%. The most frequent 3-factor combination (41.6%, 95% CI 37.9%-45.3%) of metabolic syndrome criteria consisted of being overweight or obese, having elevated BP and hypertriglyceridemia. Half of metabolic syndrome cases (51.3%, 95% CI 47.6%-55.0%) were missing measures for fasting blood glucose, and one-fifth were missing a hemoglobin A_1c (HbA_1c) level. Notably, most young adults with a BMI of 25 or greater were missing HbA_1c (68.7%, 95% CI 67.6%-69.8%), fasting blood glucose (84.0%, 95% CI 83.2%-84.8%) and triglyceride testing (79.0%, 95% CI 78.1%-79.9%).

INTERPRETATION

We have shown that our case definition is feasible in identifying early-onset metabolic syndrome using EMR data; however, the degree of missing data limits the feasibility in assessing prevalence. Further investigation is required to validate this case definition for metabolic syndrome in the EMR data, which may involve comparing this definition to other validated metabolic syndrome case definitions.

The performance of anthropometric tools to determine obesity: a systematic review and meta-analysis

The aim of this systematic review was to assess the performance of anthropometric tools to determine obesity in the general population (CRD42018086888). Our review included 32 studies. To detect obesity with body mass index (BMI), the meta-analyses rendered a sensitivity of 51.4% (95% CI 38.5-64.2%) and a specificity of 95.4% (95% CI 90.7-97.8%) in women, and 49.6% (95% CI 34.8-64.5%) and 97.3% (95% CI 92.1-99.1%), respectively, in men. For waist circumference (WC), the summary estimates for the sensitivity were 62.4% (95% CI 49.2-73.9%) and 88.1% for the specificity (95% CI 77.0-94.2%) in men, and 57.0% (95% CI 32.2-79.0%) and 94.8% (95% CI 85.8-98.2%), respectively, in women. The data were insufficient to pool the results for waist-to-hip ratio (WHR) and waist-to-height ratio (WHtR) but were similar to BMI and WC. In conclusion, BMI and WC have serious limitations for use as obesity screening tools in clinical practice despite their widespread use. No evidence supports that WHR and WHtR are more suitable than BMI or WC to assess body fat. However, due to the lack of more accurate and feasible alternatives, BMI and WC might still have a role as initial tools for assessing individuals for excess adiposity until new evidence emerges.

Factors affecting access and use of preventive and weight management care: A public health lens

Obesity is an important risk factor for various chronic diseases. While people with obesity use the health system more and incur higher costs, they may forego using preventive care services (e.g., gynecological cancer screenings) due to issues of service use and service access. The aim of this paper was to use a public health lens to elucidate system level factors that affect healthcare access and utilization for preventive and weight management care by patients with obesity. Some elucidated factors include lack of access to a Primary Care Provider (PCP) and multidisciplinary healthcare settings, gender of the PCP, duration of medical visits and health professionals' attitudes about obesity. We highlight potential strategies for leaders to use when improving access and use of health services by patients with obesity in Canada and the need for future empirical studies in this research area.

Nutrition and obesity care in multidisciplinary primary care settings in Ontario, Canada: Short duration of visits and complex health problems perceived as barriers

Nutrition care in the primary care setting is integral in obesity management, but there is a substantial gap between patients who would benefit from this service and those receiving it. This study provides an in-depth understanding of how relatively new multidisciplinary primary care settings may be affecting nutrition care practices of family physicians and nurse practitioners. This qualitative comparative case study sought to assess nutrition care practices in three different types of multidisciplinary clinics (2 Family Health Teams, 3 Community Health Centers, 1 Nurse Practitioner-Led Clinic) in Ontario, Canada. Individual semi-structured interviews were conducted with nurse practitioners (n = 13) and family physicians (n = 7) in fall 2017. Data analysis was conducted using NVivo Software. The integrated approach was used for elucidating codes and themes. Findings suggest that suboptimal duration of medical visits and increasing prevalence of complex patients were reported by most participants and were perceived as barriers for addressing nutrition and obesity. However, improved nutrition care was fostered through Electronic Medical Records, primary care providers' positive attitude towards nutrition and cost-free dietitian services at point of access. Site-specific challenges, such as duration of medical visits, incentive programs, access to dietitians on site, and continued professional development could enhance nutritional care for weight management in these multidisciplinary primary care settings.

Nutrition care practices of primary care providers for weight management in multidisciplinary primary care settings in Ontario, Canada - a qualitative study

Background

Despite the recommended guidelines on addressing diet for the management and prevention of obesity in primary care, the literature highlights that their implementation has been suboptimal. In this paper, we provide an in-depth understanding of current nutrition-related weight management practices of primary care providers (PCPs) working in relatively new multidisciplinary health care settings in Ontario.

Methods

Three types of multidisciplinary primary care settings were included (2 Family Health Teams, 3 Community Health Centres and 1 Nurse Practitioner-Led Clinic). Participants (n = 20) included in this study were nurse practitioners (n = 13) and family physicians (n = 7) supporting care for adult patients (18 years or older). In-depth interviews were transcribed, coded and the content was analyzed using an integrated approach.

Results

Our analysis showed that most PCPs used anthropometric measures such as weight for screening patients who would benefit from nutrition counselling with a dietitian. The topic of nutrition was generally brought up either during physical examinations, when patients were diagnosed with a chronic disease, or when blood markers were out of normal range. Participants also mentioned that physical examinations are no longer occurring annually, with most PCPs offering episodic care. All participants reported utilizing dietetic referrals, noting the enablers for providing the referral, which included access to an on-site dietitian. Nonetheless, dietetic referrals were mostly used when patients had an obesity-related co-morbidity. Participants mentioned that healthy eating advice was reinforced during follow-up visits with patients only when there was enough time to do so. Electronic Health Records (EHRs) were utilized to facilitate message reinforcement by PCPs, who perceived EHRs to be helpful for viewing what was discussed in the session with the dietitian.

Conclusions

PCPs mostly used objective measures to screen for patients who would benefit from nutrition counselling rather than diet assessment, which undermines the importance of dietary intake and overemphasizes weight. With physical examinations occurring less frequently, there will be additional missed opportunities for addressing nutrition-related concerns. The presence of a dietitian on site allowed for PCPs to refer patients to nutrition counselling. Having sufficient time during medical visits and EHRs seemed to facilitate message reinforcement by PCPs in follow-up visits with patients.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0760-3) contains supplementary material, which is available to authorized users.

Current Weight Management Approaches Used by Primary Care Providers in Six Multidisciplinary Healthcare Settings in Ontario

BACKGROUND

Obesity management in primary care has been suboptimal due to lack of access to allied health professionals, time, and resources.

PURPOSE

To understand the weight management approaches used by primary care providers working in team-based settings and how they assess the most suitable approach for a patient.

METHODS

A total of 20 primary care providers (13 nurse practitioners and 7 family physicians) working in 6 multidisciplinary clinics in Ontario were interviewed. All interviews were recorded, transcribed verbatim, and coded using NVivo qualitative software. Conventional content analysis was used to inductively elucidate codes, which were then clustered into categories.

RESULTS

A referral to on-site programming was the most frequent weight management approach used. The pharmacological approach was underutilized due to adverse side effects and cost to patients. Primary care providers assessed the most suitable weight management approach based on patients': preference, level of motivation, income status and access to resources, body mass index and comorbidities, and previous weight loss attempts. Primary care providers perceived that referring to health professionals and educational resources were the approaches preferred by patients.

CONCLUSIONS

The team-based nature of these clinics allowed for referrals to various on-site professionals and/or programs. Some barriers to pursuing weight management avenues with patients were patient dependent.