Dutch General Practitioners' weight management policy for overweight and obese patients

Dutch GPs' perspectives on addressing obesity: a qualitative study

BACKGROUND

Early diagnosis and treatment of obesity in primary care may help to tackle the obesity pandemic. Nonetheless, GPs frequently fail to address obesity and demonstrate limited adherence to guidelines.

AIM

To explore Dutch GPs' perspectives on addressing obesity regarding the following three target behaviours: discussing weight; diagnosing; and referring patients with obesity.

DESIGN & SETTING

A qualitative focus group study with Dutch GPs.

METHOD

Six focus groups were conducted with a purposive sample of 21 GPs. Thematic analysis was performed using deductive coding, according to the Theoretical Domains Framework (TDF).

RESULTS

For discussing weight, the main barriers identified were a presented complaint unrelated to obesity (environmental context and resources), concerns about a negative response from the patient (beliefs about consequences), and worries about obesity being a sensitive subject to discuss (emotions). A long-term trustworthy relationship (social influences) facilitated discussing weight. For diagnosing patients with obesity, the main barriers were related to resources; for example, lack of (appropriate) measuring equipment and time (environmental context and resources). For referring patients with obesity, the main barriers were no referral options nearby (environmental context and resources), and doubts about the positive effects of the referral on weight change (beliefs about consequences).

CONCLUSION

Different barriers for discussing weight, diagnosing, and referring patients with obesity were identified, underscoring the importance for tailored interventions to these specific behaviours. Improving knowledge and skills of GPs seems insufficient as this study showed that particular attention should be paid to establishing long-term relationships, addressing GPs' beliefs about consequences, and creating a supportive environment with sufficient time and resources.

Intermediate weight changes and follow-up of dietetic treatment in primary health care: an observational study

BACKGROUND

Primary health care data have shown that most patients who were treated for overweight or obesity by a dietitian did not accomplish the recommended treatment period. It is hypothesised that a slow rate of weight loss might discourage patients from continuing dietetic treatment. This study evaluated intermediate weight changes during regular dietetic treatment in Dutch primary health care, and examined whether weight losses at previous consultations were associated with attendance at follow-up consultations.

METHODS

This observational study was based on real life practice data of overweight and obese patients during the period 2013-2017, derived from Dutch dietetic practices that participated in the Nivel Primary Care Database. Multilevel regression analyses were conducted to estimate the mean changes in body mass index (BMI) during six consecutive consultations and to calculate odds ratios for the association of weight change at previous consultations with attendance at follow-up consultations.

RESULTS

The total study population consisted of 25,588 overweight or obese patients, with a mean initial BMI of 32.7 kg/m². The BMI decreased between consecutive consultations, with the highest weight losses between the first and second consultation. After six consultations, a mean weight loss of - 1.5 kg/m² was estimated. Patients who lost weight between the two previous consultations were more likely to attend the next consultation than patients who did not lose weight or gained weight.

CONCLUSIONS

Body mass index decreased during consecutive consultations, and intermediate weight losses were associated with a higher attendance at follow-up consultations during dietetic treatment in overweight patients. Dietitians should therefore focus on discussing intermediate weight loss expectations with their patients.

Effectiveness of Individual Nutrition Education Compared to Group Education, in Improving Anthropometric and Biochemical Indices among Hypertensive Adults with Excessive Body Weight: A Randomized Controlled Trial

OBJECTIVE

The study aims to compare the effectiveness of individual and group nutrition education methods in improving key anthropometric and biochemical markers in drug-treated, overweight-obese hypertensive adults.

METHODS

The randomized trial included 170 patients with pharmacologically well-controlled primary hypertension and body mass index (BMI) ≥ 25 kg/m2. For six months, the patients received six sessions, either one-to-one individual nutrition education (IE, n = 89) or group education (GE, n = 81), developed by dietitians. Anthropometric measurements, body composition, and fasting measures of biochemical parameters were obtained at baseline and after six months of intervention.

RESULTS

150 patients completed the nutrition education program. The IE group significantly improved in many parameters compared to the GE group, including weight (p < 0.001), waist circumference (p < 0.001), BMI (p < 0.001), systolic and diastolic blood pressure (BP) (p < 0.001), fasting plasma glucose (p = 0.011), oral glucose tolerance test (OGGT) (p = 0.030), and insulin resistance (homeostatic model assessment of insulin resistance, HOMA-IR) (p < 0.001). The groups did not differ in terms of total cholesterol, high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C) concentrations.

CONCLUSION

Individual nutrition education is more effective than group education in terms of improving anthropometric and biochemical indices in overweight-obese hypertensive adults.

Achievement of weight loss in patients with overweight during dietetic treatment in primary health care

Introduction

Dietitians are the preferred primary health care professionals for nutritional care in overweight patients. Guidelines for dietitians recommend a weight reduction of ≥ 5% of initial body weight after one year of treatment. The purpose of this study was to evaluate weight change in patients with overweight who were treated by dietitians in Dutch primary health care, and to identify patient characteristics that were associated with it.

Materials and methods

This observational study data was based on real life practice data of patients with overweight during the period 2013–2017, derived from dietetic practices that participated in the Nivel Primary Care Database. Multilevel linear regression analyses were performed to investigate weight change after dietetic treatment and to explore associations with patient characteristics.

Results

In total, data were evaluated from 56 dietetic practices and 4722 patients with a body mass index (BMI) ≥ 25 kg/m². The mean treatment time was 3 hours within an average timeframe of 5 months. Overall, patients had a mean weight change of -3.5% (95% CI: -3.8; -3.1) of their initial body weight, and a quarter of the patients reached a weight loss of 5% or more, despite the fact that most patients did not meet the recommended treatment duration of at least one year. The mean BMI change was -1.1 kg/m² (95% CI: -1.2; -1.0). Higher weight reductions were shown for patients with a higher initial BMI and for patients with a longer treatment time. Sex and age were not associated with weight change, and patients with other dietetic diagnoses, such as diabetes, hypertension, and hypercholesterolemia, had lower weight reductions.

Conclusions

This study showed that dietetic treatment in primary health care coincided with modest weight reduction in patients with overweight. The weight loss goals were not reached for most patients, which was possibly due to a low treatment adherence.

Recording of weight in electronic health records: an observational study in general practice

Background

Routine weight recording in electronic health records (EHRs) could assist general practitioners (GPs) in the identification, prevention, and management of overweight patients. However, the extent to which weight management is embedded in general practice in the Netherlands has not been investigated. The purpose of this study was to evaluate the frequency of weight recording in general practice in the Netherlands for patients who self-reported as being overweight. The specific objectives of this study were to assess whether weight recording varied according to patient characteristics, and to determine the frequency of weight recording over time for patients with and without a chronic condition related to being overweight.

Methods

Baseline data from the Occupational and Environmental Health Cohort Study (2012) were combined with data from EHRs of general practices (2012–2015). Data concerned 3446 self-reported overweight patients who visited their GP in 2012, and 1516 patients who visited their GP every year between 2012 and 2015. Logistic multilevel regression analyses were performed to identify associations between patient characteristics and weight recording.

Results

In 2012, weight was recorded in the EHRs of a quarter of patients who self-reported as being overweight. Greater age, lower education level, higher self-reported body mass index, and the presence of diabetes mellitus, chronic obstructive pulmonary disease, and/or cardiovascular disorders were associated with higher rates of weight recording. The strongest association was found for diabetes mellitus (adjusted OR = 10.3; 95% CI [7.3, 14.5]). Between 2012 and 2015, 90% of patients with diabetes mellitus had at least one weight measurement recorded in their EHR. In the group of patients without a chronic condition related to being overweight, this percentage was 33%.

Conclusions

Weight was frequently recorded for overweight patients with a chronic condition, for whom regular weight measurement is recommended in clinical guidelines, and for which weight recording is a performance indicator as part of the payment system. For younger patients and those without a chronic condition related to being overweight, weight was less frequently recorded. For these patients, routine recording of weight in EHRs deserves more attention, with the aim to support early recognition and treatment of overweight.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0863-x) contains supplementary material, which is available to authorized users.

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.

Role of the family doctor in the management of adults with obesity: a scoping review

OBJECTIVES

Obesity management is an important issue for the international primary care community. This scoping review examines the literature describing the role of the family doctor in managing adults with obesity. The methods were prospectively published and followed Joanna Briggs Institute methodology.

SETTING

Primary care. Adult patients.

INCLUDED PAPERS

Peer-reviewed and grey literature with the keywords obesity, primary care and family doctors. All literature published up to September 2015. 3294 non-duplicate papers were identified and 225 articles included after full-text review.

PRIMARY AND SECONDARY OUTCOME MEASURES

Data were extracted on the family doctors' involvement in different aspects of management, and whether whole person and person-centred care were explicitly mentioned.

RESULTS

110 papers described interventions in primary care and family doctors were always involved in diagnosing obesity and often in recruitment of participants. A clear description of the provider involved in an intervention was often lacking. It was difficult to determine if interventions took account of whole person and person-centredness. Most opinion papers and clinical overviews described an extensive role for the family doctor in management; in contrast, research on current practices depicted obesity as undermanaged by family doctors. International guidelines varied in their description of the role of the family doctor with a more extensive role suggested by guidelines from family medicine organisations.

CONCLUSIONS

There is a disconnect between how family doctors are involved in primary care interventions, the message in clinical overviews and opinion papers, and observed current practice of family doctors. The role of family doctors in international guidelines for obesity may reflect the strength of primary care in the originating health system. Reporting of primary care interventions could be improved by enhanced descriptions of the providers involved and explanation of how the pillars of primary care are used in intervention development.

Talk weight: an observational study of communication about patient weight in primary care consultations

BACKGROUND

Obesity is a major public health issue and primary care practitioners are well placed to opportunistically raise the issue of overweight or obesity with their patients.

AIM AND METHODS

This study investigated the prevalence of weight discussion in primary care consultations with overweight and obese patients, in a practice in Fife, Scotland, and described weight-related communication using video analysis.

FINDINGS

Weight was raised in 25% of consultations with overweight and obese patients. GPs initiated weight discussion more often than patients; however, these attempts were often blocked by patients. Weight-related outcomes were more common when patients initiated the weight discussion. This study confirms the potential of video analysis for understanding primary care weight discussion. It also suggests that GPs may benefit from a communication-based intervention to tackle patient blocking behaviours and contributes to the evidence suggesting that interventions targeted to increase the prevalence of weight-related discussions with their patients are needed.