GPs once had an exclusive primary-care role in managing patients’ weight. But OTC medication, and an explosion of commercial motivation and weight-intervention services, has changed this, writes Dr Sinéad Murphy
Perhaps the single biggest change in terms of weight management in Ireland in recent years has been the availability of a half-strength orlistat in the pharmacy setting.
Whilst this was a revolutionary move in terms of the regulation of medicines in Ireland, it did not elicit much public comment at the time. I know that some doctors are of the opinion that direct-to-consumer availability of orlistat is not ideal and that over-the-counter (OTC) weight-loss treatments do little to address the overall obesity issue.
Others believe the significant exposure the drug has been getting in magazine advertisements and in pharmacy promotions could have a positive outcome.
It will suit some patients, who will lose weight. And if a patient comes into their GP surgery and reveals they are thinking about using an OTC weight-loss medicine, I think this can open a potentially useful dialogue on weight.
Direct access
Unlike the pharmacist, the GP will have immediate and direct access to the individual’s detailed long-term history and perhaps to other factors contributing to their current situation. The GP will be able to explain that quick fixes rarely work in isolation and can aim to develop a meaningful engagement about other issues, such as a patient’s lifestyle.
There is an alternative scenario: the possibility that unsuccessful exposure to OTC medication could jeopardise a GP’s treatment options and limit opportunities to revisit treatment with a stronger intervention. I know that colleagues have also expressed fears that some pharmacies do not have the room for private consultations. The Consumers’ Association of Ireland and various newspaper investigations have also revealed that those who do not meet the BMI criteria are also managing to inappropriately access the drug.
Another significant but separate evolution in the weight management primary-care landscape has been a huge increase in the number of people offering weight-management services.
Sales pitch
Some are excellent, but others, unfortunately, are much less so. The one thing that can be said about GPs and weight advice is that we have no hidden agenda. We will not be selling bars, shakes and vitamin supplements and all these other things. And more discerning and aware members of the public are beginning to approach us about their weight, because they are reassured by the knowledge that we will not try to sell them anything.
However, because GPs are not selling products and cannot therefore offer free consults, not everyone views a visit to their family doctor to discuss losing weight as an attractive option.
Given such ongoing change, it is useful to restate that GPs are in an optimal position to sit down and talk to members of the public about diet, lifestyle and even pharmacological intervention. We hold their medical records, and ideally, we will have been in a position to monitor the gradual onset of weight-related risk and identify early signs of the disease’s co-morbidities. Thus, we are uniquely placed to manage the patient’s journey away from risk.
The participation of GPs is essential if the management of obesity is ever to be tackled in Ireland, or even stemmed before we start to turn it. Of course, there has to be a public health dimension, but this will chiefly be in terms of prevention.
Indeed, in terms of prolonged obesity, 80-90 per cent of all intervention effort should be around prevention. GPs must be allocated an obesity management role that reflects their unique potential for intervention, and then resourced accordingly.
Negligence
Of course, evolving medical negligence requirements may force this role upon us. I think it is no exaggeration to suggest we are moving toward a situation in primary care where physicians who do not routinely weigh their patient or who may not regularly take their blood pressure (BP) are perhaps leaving themselves open to risk.
The problem with this, of course, is that weight management is much more than placing someone on the surgery scales or taking a BP reading. That aspect of intervention is relatively easy: we have all got numerous leaflets and advice on blood pressure – we have even got 24-hour monitors, clear parameters and guidelines. But, having recorded weight and BP, we move into a situation where intervention is difficult and extremely time consuming.
Focus on weight
Because of the stratospheric amount of potential work that is involved, GPs would benefit from having a more precise focus regarding general weight management in the primary care setting. We need to encourage and assist GPs to individualise their patients in terms of the specific risk they face. I think the real difference a GP will make in weighing a patient is to advise them that even a relatively small amount of sustained weight loss (for example, 5-10 per cent over a modest time period of perhaps three to six months) is a realistic and achievable focus and can make an impact on their overall risk profile.
Professor Donal O’Shea advises that any GP who can get a patient’s BMI down from 28 or 29 to 26 will deliver a huge potential health benefit. That is precisely where ten minutes of primary-care intervention can deliver massive benefit.
I think most people whose BMI is 29 think they are grand, that they do not have a weight issue. I also think GPs underestimate the amount of difference they can make with a simple comment such as, ‘Did you know you are X amount overweight?’ and ‘If you get it back to here, or get it down by 5 per cent or 10 per cent, you’ll really reduce your risk of X.’
Such an approach will also give the GP an opportunity to advise the patient in question that losing this small amount of weight will result in them feeling much better and more energetic.
We have all had those patients who tell us that they feel tired all the time. There may well be a subtle association between their symptoms and a gradual weight gain – perhaps it is no more than ten kilos and maybe they have stopped taking the exercise they used to.
Interventions
Engagement on weight issues is somewhat similar to intervention on smoking. GPs often feel it is a waste of time asking somebody, ‘Have you thought about stopping?’
Why bother even saying it, if the individual is not ready to stop? But in fact, even if it is only for a little while, that person goes out of the surgery and does think about smoking on a subconscious level. The next time they come to you, they may say, ‘Actually. I’m thinking of stopping.’ Often, the little interventions do matter.
I would also be a strong advocate for the introduction of a national ‘Know Your BMI’ campaign, which would inform people of the importance of this measure and encourage them, in partnership with their GP, to measure and document it.
It has worked in terms of people knowing about the importance of cholesterol and LDL, perhaps because the pharmaceutical industry actually actively resourced it. There are very few people now who do not know about the importance of that measure as a danger point.
Resource
Of course, the biggest barrier to encouraging GPs to intervene in weight management is one of resources. Unfortunately, I think everybody anticipates it is unlikely there will be significant funding put behind weight-management initiatives for the foreseeable future. This is perhaps why some also believe this serious clinical issue has been allowed fall off our health radar.
However, the consequences of Ireland’s increasing obesity problem are being encountered in general practice surgeries around the country many times every day of each week. I think most GPs, despite the challenges, will do whatever they can to help patients reduce risk and they should at least be encouraged and supported.
l Dr Sinéad Murphy is a Galway-based GP and ICGP representative on the HSE/Department of Health inter-sectoral group on obesity
About admin
Loading ...
