ACADEMY OF MEDICAL ROYAL COLLEGES PROJECT ON OBESITY Response from Dr Rachel Pryke, RCGP Clinical Champion for Nutrition

for Health, representing views of the RCGP.

The RCGP is fully supportive of the aims of the Academy of Royal Colleges Obesity Steering Group project to improve, coordinate and facilitate clinician involvement in obesity care. The responses relate largely to a general practice provider viewpoint but also reflects their position as leading system change from a commissioning perspective. Summary of suggested action points Define core roles and responsibilities for different clinicians Explore more sensitive and specific measures of work done and outputs achieved from obesity- and lifestyle-related services. BMI change is inadequate as sole measure. Work with commercial partners to develop ways of gathering effectiveness data from NHS-funded weight management groups. Approach GP computer system providers to explore how child BMI data can be presented appropriately. Assess whether professional exam question setting can be used to stimulate improved training for new doctors Review/update the RCP document The training of health professionals for the prevention and treatment of overweight and obesity, to guide clinician-specific training and core competencies. Assess whether local incentive payments for undertaking obesity and malnutrition training could be used to increase uptake in a similar way to recent improved training in palliative care. Encourage incorporation of obesity training sessions within mixed training programmes for other clinical topics, to improve general exposure to obesity education and, in particular, to attitudinal aspects of care. Encourage broad training in nutrition and malnutrition as well as obesity management as they are all part of the same spectrum. Support steps to control advertising of unhealthy foods to children Working as clinical commissioners, develop and implement a wider system strategy in partnership with the Local Authority in response to the Joint Strategic Needs Assessment while remaining accountable to the Health and Wellbeing Boards and member practices.

Clinical interventions Role definition for differing clinicians.

With recognition of the need to take a team approach to obesity and that members of a team do not all carry out the same function, a fundamental step is to define the specific roles of individual clinicians so that each clinicians responsibility reflects their skills and training plus the way they usually interact with patients (eg consultation length, expectation of patient regarding what the appointment is about, facility for follow up etc). Evidence (1,2 ) shows that different health professionals (here, comparisons between commercial slimming groups, pharmacists and GPs/practice nurses) achieve different results despite taking a similar approach, which is unsurprising when their different roles, clinical setting and training are borne in mind. Hence, for GPs, evidence now clarifies that GPs should not be running first line weight management clinics themselves as they are least effective in this role. Rather, an important aspect of the GPs role is to signpost the patient to an appropriate source of support, such as a commercial weight management group. Further facets of the GPs role include Assessing and treating low self esteem, emotional fragility and underlying depression Developing perspectives on varied health risks such as alcohol, smoking, activity and diet Taking an holistic view of health priorities and intercurrent conditions, for example pregnancy, disability, cancer treatment Recognising how family issues are relevant to health behaviour Working with local communities to encourage a positive approach to general physical and mental health including healthy eating and exercise. Aims of improved training for the GP workforce should result in GPs being capable of undertaking the following core approaches: Sensitively raise awareness of weight issues and impact on health Understand the complexity of obesity and the need to leave judgemental attitudes behind Undertake and convey metabolic risk assessment to patients Help patients set relevant and feasible goals and balance this with the needs of other health issues and health promotion areas such as smoking Be aware of local community services and bariatric care pathways Potentially, a sub-group of GPs may develop special interest skills to fill the serviceprovision gap for patients unsuccessful with a commercial slimming group but not suitable for a bariatric pathway. Further research is needed in this area. Recognising emotional fragility linked to obesity It is important to raise awareness and address the significant problem of obesityrelated depression: where patients struggle with life in general and eating/obesity in

particular, food may be the single comforting and enjoyable part of the day. Suggesting abandoning their only source of enjoyment is frankly a recipe for failure. Time, skill, education and support are needed to guide patients towards feasible changes and to discover that health benefits can make up for any perceived deficiencies of a healthier lifestyle. More work on clarifying the psychological profile of obese patients is warranted to inform prevention and treatment strategies in primary care as well as other settings. Measuring obesity-related work Problems arise from historically simplistic approaches taken towards measuring activity in obesity work which typically requires demonstration of BMI change as the main determinant of impact. Other important elements of health gain are harder to measure, (e.g. fitness, dietary quality, well-being, balance and falls risk, impact upon cardiovascular risk etc,) and in the past, ongoing funding of any service has typically been dictated by its sole ability to achieve numerical BMI change. With recognition of the more specific roles of different clinicians carrying out facets of work that contribute towards lifestyle change, we need a better understanding of how this activity can be measured and funded. It would be inappropriate to use BMI change to measure the groundwork done by a GP whose job is to focus on awareness raising, emotional fragility assessment, health relevance assessment, goal setting and signposting to ensure efficient uptake of local public health services. The impact of narrow BMI-focused goals does not only affect GPs; For example, Worcestershire PCT have just withdrawn their funded Weight Watchers voucher scheme, despite high quality published evidence of effectiveness, due to the need to demonstrate BMI change in order to continue funding. Their argument is that once the voucher is issued they get no further feedback and hence cannot justify this expenditure. It is hoped the Academy will work with such commercial partners to address the feedback requirements of funding partners including development of outcome metrics and baseline assessment. Further limitations of BMI change as impact-indicator from lifestyle improvement relate to the difficulties in leaving the obese range. Small yet clinically significant amounts of weight loss may still leave a patient in the obese category and so it would be difficult to demonstrate impact from lifestyle programmes by focusing on obesity prevalence data. Recording child weight and height data in primary care There are problems around recording and interpreting child measurements because most GP computer systems will not calculate a childs BMI automatically, due to the need to refer to an age- and sex-appropriate BMI chart for interpretation. It would be beneficial to work with the main GP computer companies to address this issue as it

currently forms another barrier to GP involvement in obesity management for children.

Training Improved training of health professionals is important so that health professionals are aware of the health and medical consequences of obesity, have insight into the social and environmental determinants of obesity and have the ability and confidence to broach issues about weight, nutrition and exercise with patients. Improved training may address some of the barriers to engaging health professionals in preventing and tackling obesity including the perception that obesity is too difficult to tackle and that it is not a medical problem. The initial interaction with the health professional can influence whether or not a patient seriously contemplates making a behaviour change. Training for new clinicians: In the past, obesity and nutrition training for all doctors has been haphazard or virtually non-existent. The forthcoming version of the GP training curriculum will include reference to obesity in both the metabolic and health promotion sections, with the expectation of improved training for future doctors, as long as guidance over content of that training is established. If this is left to existing trainers to decide then it may continue to be haphazard, bearing in mind their own lack of training in nutrition. The role of exam question setting may be highly relevant in supporting effective curriculum development. It is timely to review and build upon the RCP document The training of health professionals for the prevention and treatment of overweight and obesity, (Dec 2010) Core competencies for physicians, radiologists, surgeons, paediatricians, psychiatrists, GPs etc all differ and a revision of this document may be a method of conveying the different assessment skills, communication skills and management options relevant to each.

Training for existing clinicians: consideration is needed to evaluate the most appropriate training resources and opportunities to support Continuing Professional Development. How should this training be funded and could it be linked in some way to incentive payments for clinical activity? Parallels could be drawn with the improved profile of palliative care; some PCTs have set out funding schemes whereby training modules form part of the essential requirement for service provision and hence funding. It is important to recognise that GP attendance at training events is commonly stimulated by QOF (Quality and Outcome Framework) priorities. Where topics do not attract significant QOF targets, incentives to attend training events are poor even if

the topic is clinically important, as in the case of obesity and malnutrition. Bearing in mind the high relevance of obesity to virtually all aspects of health, it would be beneficial to encourage more clinical training days to include a session(s) on obesity and nutrition within a mixed programme, because training events dedicated solely to obesity are commonly poorly attended or even cancelled due to lack of uptake. Attitudinal change: Historical clinician attitudes need to change, recognising our improved understanding of the complexity of obesity. There is a pressing need for clinicians to avoid being judgemental and dogmatic and to move away from giving dismissive advice to lose weight using the threat of well-recognised serious health implications to try to frighten patients into some sort of action. These approaches simply add to the existing burden of guilt and failure felt by many obese patients, (my weight is my fault) confirm that doctors are no use in helping with weight problems (doctors just tell me off and dont listen) and alienate patients from seeking more help (I wont ask for help as I feel worthless and I know nothing works for me anyway). When challenged with a problem that feels insoluble, patients typically will respond with either denial (its not what I eat...) or defensive aggression (dont you dare talk to me about weight). Communication skills training can help doctors recognise the need to acknowledge the difficulties the patient has and explore the barriers that the patient perceives in making changes.

Scope of nutrition training: This project offers an opportunity to highlight the need for broad nutrition training, not just weight management. This should include malnutrition, common nutritional deficiencies and food intolerances, plus the fundamentals of childhood eating behaviour and infant nutrition. Motivational interviewing is a generic skill that can help in improving communication skills. The National Child Measuring Programme, NCMP, which is currently being expanded to include informing parents of their childs measurements, assumes a degree of engagement by GPs to manage children highlighted as overweight or obese. (3) Clinician training is urgently required to support this work, but funding for both training and for work undertaken needs to be addressed as this is new work not covered under existing working practice. Discussions with the Department of Health have, to date, produced no answers to this problem due to reductions in the budget supporting the NCMP.

Need for further research evidence: Specific evidence is needed regarding the following questions: Do slimming clubs work as effectively if self-funded rather than if NHS-funded vouchers are issued?

How do we help patients that have been unsuccessful with a first line commercial weight loss club but do not fit referral criteria via bariatric pathway? Is this where GPs should focus their in-house weight management support? Clinical Commissioning Interventions Clinical interventions are likely to be much more effective if they are part of a wider integrated commissioning strategy for obesity. GPs as clinical commissioners are in a strong position to articulate the importance of prioritising obesity, with all its demographic variations, as a long term public health priority within Joint Strategic Needs Assessments. Although this may be driven by Health and Wellbeing Boards, it encompasses wider issues than social services to include education, transport, planning, leisure, regeneration and community development. Funding and commissioning an Obesity Strategy should be seen as a joint responsibility of the Clinical Commissioning Group and Local Authority. Statutory organisations are unlikely to invest unless they can demonstrate real population outcomes so we would encourage baseline data sharing within Information Governance rules as well as clinical commitment. Specialist, tier three, weight programmes would have to be commissioned within the pathway for those with morbid obesity whose health is at significant clinical risk and for those in whom bariatric surgery is being considered. There is a role for the Academy Obesity Group in collating and advising on examples of good practice but detailed implementation will be for local determination. Action that can be taken by individuals Adjusting behavioural norms There are many examples of inappropriate eating tendencies that have now become accepted as standard. The Academy could usefully support development of resources and wide distribution of healthy eating behaviour messages. For example; There is a pressing need to recreate a structure to understanding when different foods are appropriate, (eg party foods are for parties, not every day.) The traffic light food labelling system has inherent problems because red equates to danger and risks inducing guilt, whereas it is appropriate for people to enjoy celebration foods etc in suitable settings. Evolution of the traffic light system to convey positive messages about food structures would be useful.

Abandon the concept of clearing the plate and teach individuals to slow down the pace of eating and recognise their own sense of fullness. Children need tuition in choosing appropriate portion sizes where this decision is dictated by carers or the food industry, a childs ability to eat to appetite is diminished. Move away from the concept of kids food, both on an individual basis and promotionally. Children learn to develop a taste for their local staple foods by copying the example of adults; hence serving bland, predictable kids food rather than sharing family foods introduces limitations to a childs ability to develop a taste for well-balanced family meals. Reinstate the importance of shared mealtimes, which are a fundamental time for learning eating behaviours and form an opportunity to focus on nutrition in addition to pleasure, (eg breakfast could be described as a medicine meal as it is an opportunity for ensuring the day starts with some fibre, calcium, vitamins and minerals and complex carbohydrates). Embed the message to use non-food rewards for children rather than treatfoods, which increase the desirability of those foods. Many fundamental eating behaviours are well-described by Birch and Fisher (4); an example of a training package is available through the HENRY programme. (5) Improve patient understanding re common myths and misconceptions Public awareness programmes can help reinforce accurate messages. For example, Weight change in response to exercise: The body will self-regulate weight in response to increased exercise. Hence, exercise leads to weight reduction only if there is a degree of calorie restriction too (however, this should not detract from ensuring that the wider health benefits associated with exercise are understood). Hidden calories are present in many foods, in particular sweetened drinks, but they have no impact on appetite. Healthy oils, eg olive oil, have the same calorie content as a less healthy alternative

The environment The RCGP is concerned about reducing control over advertising of unhealthy foods to children and increasing product placement in TV and films. Marketing techniques are effective, not only, for example, by triggering pester power but also by use of marketing techniques such as brand positioning and brand awareness to skew common perceptions that unhealthy foods are part of normal culture. Many people know junk foods are unhealthy but eat them regularly anyway due to their perceived

position in the staple diet. It is hoped the Academy report will add further pressure against reducing controls on advertising to children. Dr Rachel Pryke RCGP Clinical Champion for Nutrition for Health

References 1. Jolly K, Lewis A, Beach J, et al. Comparison of range of commercial or primary care led weight reduction programmes with minimal intervention control for weight loss in obesity: Lighten Up randomised controlled trial. BMJ 2011;343:d6500 doi: 10.1136/bmj.d6500 2. Jebb SA, Ahern AL, Olson AD, Aston LM, et al. Primary care referral to a commercial provider for weight loss treatment versus standard care: a randomised controlled trial. Lancet 2011 Oct 22: 3378 (9801): 1485-92. Epub 2011 Sep 7 3. National Child Measuring Programme, Department of Health. 4. Birch L, Fisher J. Development of Eating Behaviours among children and adolescents. Paediatrics. 1998; 101(3 Pt 2): 539-549 5. Health, exercise, nutrition for the really young. http://www.henry.org.uk/training-courses.html
www.dh.gov.uk/health/2012/04/ncmp-2012-13