Managing obesity in primary care: interview with Dr Abd Tahrani

Managing obesity in primary care: interview with Dr Abd Tahrani

We are pleased to share our interview with Dr Abd Tahrani, who recently worked with a team of experts to develop helpful guidance and a novel treatment algorithm for obesity management in primary care.

Abd, great to meet with you. We are really excited about the new resources you and the team have developed for supporting clinical care in England, and believe that our clinical colleagues across Europe will find these tools interesting and helpful as well.  Over the years, you have consistently highlighted a number of key challenges in obesity management that would suggest primary care is a crucial pathway for addressing obesity since the primary health care professionals are  often the first point-of-contact for people living with obesity, and can provide support and continuity of care if appropriately trained, equipped, and have access to necessary support services.

During the COVID-19 pandemic, obesity has come to the fore in health systems across Europe. It is important to highlight that the UK government has introduced new policies to address obesity, including plans to expand NHS weight management services and broaden access to the NHS Diabetes Prevention Programme (DPP).

These learnings within these guidelines seems particularly urgent under the current circumstances since patients living with overweight or obesity during the coronavirus pandemic have experienced significantly more negative outcomes when contracting COVID-19. People with obesity have now been recognised as more medically vulnerable to COVID-19 by the EU Commission.

EASO recognises obesity as a chronic – but treatable – disease, and also a gateway to other long-term diseases and NCDs including Type 2 diabetes, cardiovascular diseases, and cancer.

Abd, please describe the impetus for developing these helpful resources

Thank you Sheree and EASO, for highlighting our recent work. As you have said, obesity is a chronic disease and is linked to many NCDs, but it is for this reason that obesity also offers an opportunity to improve the health of the nation and reduce the health, social and economic burden of NCDs by improving access to treatment and improving care delivered to people living with obesity.

An important player in obesity management is primary care. The NHS realised may years ago that the mainstay of Type 2 diabetes management should be within primary care; this approach has been very successful in improving the standards of care and achieving treatment targets for patients with Type 2 diabetes with the introduction of the quality and outcomes framework. With this backdrop it is important to note that obesity is no different, it is a chronic non-communicable disease, in which primary care can play an important role in clinical management, especially since most people living with obesity don’t have access to specialised services in secondary or tertiary care.  

However, we know that primary care HCPs face many challenges in regards to obesity management, including lack of training, resources, infrastructure (appropriate equipment for example), staffing (availability of dietitians, for instance) and downstream services (such as Tiers 2, 3 or 4 weight management services). Hence, we believe that providing simple and pragmatic guidance to Primary Care HCPs that can aid weight management was timely and important. 

It’s great to see that there was a multidisciplinary expert team involved in devising this tool, representing a broad spectrum of expertise collaborating on this initiative. 

When I was first approached regarding the development of these guidelines, the first thing that crossed my mind was the need to have an excellent multidisciplinary team. Otherwise the guidelines will not be practical and would inevitably lack important and critical insights. Hence, we have assembled an excellent team of experts with the necessary skills for these guidelines including Helen Parretti, a Primary Care Physician with specialist interest in obesity and post bariatric surgery care; Mary OKane, a Consultant Dietitian with extensive experience in adult weight management including post-bariatric surgery care, Hasan Chowhan, a Primary Care Physician and a commissioner, Denise Ratcliffe, a Consultant Clinical Psychologist with special interest in weight management and Sarah Le Brocq a person with lived experience with obesity and a patient advocate.

The guidelines presented here describing the key role of GPs and approaches to obesity management seem both comprehensive and accessible, focusing on providing access to both comprehensive and non-stigmatising care. Ask Assess and Advise – simple and memorable language and tools for clinicians.

Please tell us more about the algorithm.

The algorithm aimed to provide the primary care team with brief, practical and effective advice regarding weight management. We have focused the approach on the important steps of how to start the conversation (Ask), the assessment needed in terms of root causes and disease severity (Assess) and the shared decision making process with patients regarding developing and implementing a management plan (Advise). Crucially, the algorithm followed a patient centred approach.

Within the context of these guidelines, what will the role of the GP be?

In these guidelines the GP plays the most important role. The guidelines highlight that the algorithm does not apply for one clinic visit and emphasises the need for multiple appointment and long term support to achieve the patients’ aims. The GP role starts by raising the topic of obesity management with the patient appropriately through to developing an obesity  management plan in collaboration with the patient, after assessing the root causes of weight gain, assessing patients in the short and longer term to achieve agreed treatment targets. This could obviously include referrals to other services or HCPs based on the needs of the patient and available resources.

There is a an excellent section in the guidance on attitude, approach and language use. Please tell us more.

Yes, obesity stigma is very common in the health care system. Stigmatising prejudiced concepts regarding obesity such as laziness, greediness, lack of moral fibre…etc are damaging to patients and do not help people living with obesity lose weight. Obesity stigma has been shown to negatively impact the  doctor-patient relationship and the patients mental health and has been shown to worsen obesity and other health conditions. Hence, it is absolutely crucial that health care professionals treating people living with obesity to develop an non-judgmental non stigmatizing approach. One key aspect of this approach is related to the choice of words when communicating with the patients. Hence, we have put a lot of emphasis on the language and approach.

The multi-disciplinary guideline development group includes a section on weight management tools and strategies and also describes the need for life-long post bariatric follow -up care for patients who have surgery, initially within the bariatric service and over the course of a patient’s lifetime within primary care.

Currently, NHS patients are discharged from hospital care 2 years post-bariatric surgery, and follow up is left to primary care. Despite the existence of helpful guidelines from the RCGP, most patients are probably not receiving the appropriate follow up care, as shown by a recent study published by Helen Parretti in collaboration with myself and others in the BJGP. This could be due to multiple factors, some of which relate to primary care practices and others which may relate to patients. A lack of appropriate follow up could expose patients to complications, including severe nutritional deficiencies and other significant health challenges. Hence, we believe it is very important to provide brief (less than 15 lines) but essential advice to our primary care colleagues regarding the core aspects of long term post-bariatric care.

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