A survey of GPs in Scotland - Nature

European Journal of Clinical Nutrition (1999) 53, Suppl 2, S44±S48 ß 1999 Stockton Press. All rights reserved 0954±3007/99 $12.00 http://www.stockton-press.co.uk/ejcn

Who gets what treatment for obesity? A survey of GPs in Scotland S Eley Morris1*, MEJ Lean1, CR Hankey1 and C Hunter2 1

Department of Human Nutrition, University of Glasgow, Scotland; and 2Skene Medical Group, Aberdeenshire, Scotland

Objective: To describe the types and delivery of obesity treatment currently favoured by General Practitioners (GPs) working in Scotland. Design: Representative cross-sectional survey using a postal questionnaire which included case stories as stimuli for questions about the GPs' nutrition guidance to overweight female patients. Subjects: A systematic sample of 1400 general practitioners (GPs) from a total of 3593 GPs working in Scotland in 1997. Results: From 1363 eligible GPs, 609 returned the full questionnaire and a further 132 took part in a telephone mini-interview. Net response was 54.4% (741=1363). Almost half of the GPs (45.6%) reported that they had read the recent national clinical guideline for integrating obesity prevention with weight management (SIGN 1996). The majority of GPs (89.6%) agreed that nutrition has an important role to play in the management of disease and 82.4% agreed that they can offer healthy eating advice to patients. However, only 34.8% of GPs believed that they had been successful in treating overweight patients. Routinely used treatments involve either a dietitian, practice nurse and=or a commercial slimming group and realistic weight loss was considered one criteria of successful treatment by some GPs. Age, year quali®ed and location of practice were found to have little in¯uence over variations in GP treatment while weak associations between gender of GP and treatment were found. Conclusions: The readership of the clinical guidelines in Scotland has been moderate so far although a multidisciplinary approach to obesity treatment is recognised. Further investigations of any relationships between nutrition education-obesity treatment are needed. Sponsorship: The Chief Scientist's Of®ce of the Scottish Of®ce. Descriptors: obesity; general practitioners

Introduction

Methods

Obesity presents a challenge for Health Services and thus for health professionals in primary and secondary care across all Western countries. The prevalence of obesity in the UK, has more than doubled over the last 10 years, with over 50% of the adult population now signi®cantly overweight (Department of Health 1995). The burden on health services has been estimated at 4 ± 7% of total Health Care budgets, based on major secondary diseases, although it is likely to be in excess of this bearing in mind the large number of other secondary conditions which cannot be satisfactorily costed. Given the scale of the problem, it has been suggested that primary rather than secondary care is the appropriate setting for effective weight management (SIGN, 1996). Models of good practice for effectively preventing and managing obesity in Primary Care have not yet been established. How successful do general practitioners feel in treating the overweight? What do general practitioners do when presented with an overweight patient in their surgery? What steps do they take in managing obesity? What do they perceive as success criteria in treatment? The present study examined these questions in GPs working across all areas of Scotland.

A systematic sample of 1400 general practitioners across all areas of Scotland was drawn from the listing of the Information and Statistics Division, Scotland of 3593 GPs for 1997. Based on the information on the listing, the sample were strati®ed by health board, deprivation score (Carstairs & Morris, 1991), and seniority of general practitioner. Due to concern about the low response rates of general practitioners to questionnaires in the UK, an initial mailshot of 400 GP's was undertaken in January 1998. One hundred and eighty-®ve GPs replied from a total number of potential respondents of 388 (minus undelivered, dead, left practice, long term sick etc). This gave a return rate of 47.7%. The sampling frame was further cleaned and the questionnaire shortened. In July 1998 a larger mailshot to 1000 GPs across Scotland was carried out. With the modi®cations to the questionnaire and sampling frame, this achieved a response rate of 556 out of a potential respondent base of 975 (57.0%). This paper presents results from the combined data of a total of 741 GPs out of 1363 potential respondents (54.4%). The Improving the Nutrition and the Care of the Overweight Patient Survey questionnaire was specially developed by the team for this study. It was based on initial qualitative research and validation and included a breadth of topics such as reported weight management programme in response to a case story of a female patient presenting for a routine appointment (not for weight issues) and in response to a case story of a female patients presenting with high blood pressure (having presented before for

*Correspondence: Dr. S Eley Morris, Department of Human Nutrition, University of Glasgow, Queen Elizabeth Building, Glasgow Royal In®rmary, Scotland, G31 2ER, UK.

A survey of GPs in Scotland S Eley Morris et al

weight concerns). Opportunities for audit and feedback within the general practice were also asked, and perceived clinical skills in relation to weight management, opinions on professional involvement in patient care, opinions on nutrition and health, availability and value of training in patient care relating to weight management and the GP's personal eating habits and anthropometry. Attitudinal questions were scored on 7 point bipolar Likert scales (agree to disagree). Both waves of data collection employed the same methodology: a questionnaire was mailed, a postcard reminder sent two weeks later, two weeks later a repeat questionnaire was sent. Then for non responders to postal contacts at eight weeks a telephone interview was attempted. The telephone interview contained about one quarter of the questions of the postal questionnaire.

Results Participants Table 1 states the characteristics of the 741 respondents to the survey. Some GPs declined to provide all the personal information requested and this accounts for the total n < 741 for some of the variables. The year quali®ed in medicine ranged from 1957 ± 1997 with the average number of years in practice being 20 y. List sizes of practice ranged from 160 ± 24 000 with an average of 6911. Response From 1363 eligible GPs, 609 returned the full questionnaire and a further 132 took part in a telephone mini-interview. Net response was 54.4% (741=1363). The GPs were well representative of the population of GPs in Scotland by sex and by practice size in Scotland. Although the sample showed some variation of GP response rate by health board area, there was no evident bias in responses. Responses were higher from rural areas than more urban areas as has been observed in previous studies (Hiddink et al, 1995). Table 1 Characteristics of 741 respondents to the survey of GPs in Scotland Characteristic Sex Male Female Age group 25 ± 34 (y) 35 ± 44 (y) 45 ± 54 (y) 55 ± 65 (y) Size of practice Sole GP 2 3 4 5 6 or more GPs Location (n 597) Rural Town City Other

Knowledge of nutrition-related guidelines Under half of the GPs (45.6%) had read the national clinical guideline, Òbesity in Scotland: Integrating prevention with weight management', circulated to all GPs in 1996 (Scottish Intercollegiate Guidelines Network 1996). This was higher than the proportion of GPs (33.5%) who reported having read the Eating for Health: A Diet Action Plan for Scotland' a document aimed at a wider readership of all key players in the food network which was published in the same year (Scottish Of®ce 1996). Attitudes to nutrition guidance The majority of the GPs agreed with the statements Ì believe that nutrition has an important role to play in the management of disease' and Ìf a patient is in need of healthy eating advice I can offer this' (Table 2). On the other hand 65% of GPs, do not feel that they themselves currently offer successful treatments for obesity, with less than a quarter of GPs agreeing that patients are willing to make the dietary changes that they recommend medically. Table 3 presents the percentage of GPs agreeing with statements concerning key components of the SIGN guidelines of prevention of obesity, weight loss, weight maintenance and treatment of co-morbid conditions for example hypertension. Case stories: the initial consultation Two case stories concerning overweight female patients were presented in the questionnaire. Table 4 shows the background information given in the case stories. For case 1, which could be considered an uncomplicated problem in the absence of secondary disease, most GPs reported that they would offer guidance in healthy eating and exercise in the initial consultation. A smaller proportion would themselves offer a weight reduction plan Table 2 Numbers & Percentages of GPs with a positive answer to statements concerning nutrition guidance Positive answer Statement I believe that nutrition has an important role to play in the management of disease If a patient is in need of healthy eating advice I can offer this I have been successful in treating overweight patients Patients are generally willing to make the dietary changes I recommend

n

%

629=702

89.6

493=598

82.4

208=598

34.8

136=597

22.8

n

%

455 281

61.8 38.2

101 328 244 62

13.7 44.6 33.2 8.5

Table 3 Numbers & Percentages of GPs with a positive answer to statements concerning key components of the SIGN (1996) guidelines

27 87 116 128 130 247

3.7 11.8 15.8 17.4 17.7 33.6

Statement

142 241 163 51

23.8 40.4 27.3 8.5

Positive answer

Prevention of obesity needs to be a greater priority than treatments If a patient is in need of weight loss, I can readily advise on the best method An overweight patient needs supportive family and friends involved in his/her treatment In the treatment of hypertension, a low salt diet is indicated routinely

n

%

501=593

85.7%

493=598

82.4%

514=594

86.5%

329=593

55.5%

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Table 4 Background information given in the case stories in the questionnaire Case 1

Case 2

Female 38-years-old Patient for 15 y Issue of weight raised during routine consultation BMI 37.2 Tried dieting but regains weight

Female 50-years-old Patient for 35 y Presenting with a blood pressure of 180/105 BMI 40.9 Weight control groups and hypnotherapy have not prevented weight gain

including a rate of weight loss (56.8%) at this juncture. The set of information that the majority of GPs reported they would record in the consultation with case 1 included current eating and alcohol consumption, current level of physical activity, the patient' motivation for losing weight and expectation of weight loss, height and weight, associated symptoms and quality of life (Table 5). Elevated blood pressure, a widely recognised consequence of obesity, was incorporated in case 2. The results suggest that the reported actions during this initial consultation by the GPs, focused more on the secondary disease than on obesity itself. A physical examination was the most frequently reported action taken, followed by an evaluation of psychological problems and a discussion of the family history of obesity. A number of GPs were found to be pro-active in giving structured quantitative nutrition guidance such as prescribing an exercise plan (52.7%), issuing a diet sheet prepared by a dietitian (52.5%), advising a rate of weight loss (45.9%) or setting an ideal weight (27.1%). A small percentage ( < 6%) reported that they would discuss surgery options and drug therapy at this initial consultation (Table 6). Case stories: professional involvement in treatment Table 7 presents the reported partnerships between GPs, practice nurses, dietitians and commercial slimming groups in response to each case story. A higher proportion of the GPs (n 334, 68.2%) reported that they would be involved

Case 1

Record eating habits Record current level of physical activity Give healthy eating advice Record motivation for losing weight Measurement of height and weight Give advice on exercise Record alcohol consumption Document history of associated symptoms Record patient's expectation of weight loss Assess quality of life of patient Diets previously used and success Weight history Physical examination Family medical history Socio-economic details Advise a weight reduction plan including a target weight loss Maximum weight loss ever achieved Longest duration of weight maintenance Assessment of support from family and friends

Case stories: criteria of success There was a wide variation in ranking of criteria for the success of medical intervention. Blood pressure reduction in case 2 was ranked as the top criterion for a successful outcome (41% of the GPs), followed by a realistic weight loss (20.9%) and an improved quality of life (12.8%). In case 1, realistic weight loss was reported as the number one outcome for successful treatment by 33.4% of GPs, followed by an improved quality of life (22.2%) and an improved diet (20.8%). Table 6 Actions by GPs in initial consultation with case with secondary condition Case 2 Action Physical examination Evaluate psychological problems Discuss family history of obesity Prescribe an exercise plan Issue diet sheet prepared by a dietitian Advise a rate of weight loss Set an ideal weight Discuss surgery options Advise a very low calorie diet e.g. < 800 kcals=d Discuss drug therapy Prescribe drug therapy Prescribe anti-depressants

n

%

594 594 577 579 576 555 553 533 533 491 445 441 413 399 397 332

98.3 98.2 96.2 95.5 95.4 92.2 92.0 88.8 88.4 82.4 74.2 73.7 68.9 66.3 65.7 56.8

332 333 274

55.4 55.4 46.4

n

%

490 443 379 303 304 340 155 34 32 23 17 6

82.1 76.0 65.3 52.7 52.5 45.9 27.1 5.9 5.6 4.0 2.9 1.0

Table 7 Reported professional involvement in the treatment of the two cases Case 1 Professionals involved

Table 5 Actions by GPs in initial consultation with case 1

Action

in the treatment of case 2, the overweight female patient with blood pressure than in case 1 where no secondary disease was indicated (n 203, 44%). GPs were more likely to report that they would refer case 1 to a commercial slimming group compared to case 2 (case 1 : n 287, 62.2% vs case 2 : n 203, 41.5%). Very few GPs reported that they would manage the cases without multidisciplinary support.

Dietitian & slimming group GP, PN & dietitian PN PN & slimming group GP, PN & slimming group GP, PN, dietitian & slimming group PN & dietitian GP Dietitian, GP & slimming group PN, dietitian & slimming group GP & slimming group

Case 2 n GPs % Professionals involved n GPs % 95

20.6 GP, PN & dietitian

58 49 49

12.6 PN & slimming group 10.6 GP & PN 10.6 GP, PN, dietitian & slimming group 9.8 PN & dietitian

45 35 32 26 25 17 14

Dietitian Slimming group GP & PN

9 7 0

GP & dietitian

0

7.6 GP, PN & slimming group 6.9 GP 5.6 PN 5.4 PN, dietitian & slimming group 3.7 Dietitian, GP & slimming group 3.0 GP & slimming group 2.0 Dietitian 1.5 Slimming group 0 Dietitian & slimming group 0 GP & dietitian

GP general practitioner and PN practice nurse.

143 29.2 87 17.8 71 14.5 49 10.0 26

5.3

25

5.1

21 19 16

4.3 3.9 3.3

16

3.3

9

1.8

6 1 0

1.2 0.2 0

0

0


Demographic factors Age, year quali®ed and location of practice were found to have little in¯uence over variations in GP treatment while weak associations between gender of GP and treatment were found. In case 1, compared to their male professional counterparts, female GPs were more likely to record socioeconomic details, history of associated symptoms, previous diets and success, maximum weight loss ever and the longest period of weight maintenance. In case 2, more female GPs reported evaluating psychological problems than the male GPs. Discussion It was encouraging to ®nd that many GPs reported a belief that nutrition had an important role to play in the management of disease as this interest in the effect of nutrition on health has been shown to play an important role in the observation of overweight patients and guidance of treatment (Hiddink et al, 1997). Although only one third of the GPs had read the Eating for Health report, which described the Dietary Targets for Scotland for 2005 (Scottish Of®ce 1996), it cannot be assumed that the GPs did not know them. It has been argued that one-to-one communication with GPs is one of the most in¯uential factors to help patients change their behaviour (Hiddink et al, 1997) and their nutrition guidance could have an enormous impact on the general public as more than 70% of the general public visit their general practitioners each year (Royal College of General Practitioners, 1980). While less than half the GPs reported having read the SIGN guidelines, the aspirations of the guidelines are evident in their reported multidisciplinary approach to the two cases stories. The SIGN guidelines recommend that weight management should be undertaken primarily by members of the primary health care team (PHCT) on the grounds of accessibility, centrality of obesity to medical patients and its lack of special facilities in hospitals. It is acknowledged that the members of the PHCT may not have suf®cient motivation, time and resources to spend in the management of obesity (Hiddink et al, 1995). This view is supported by Cade & O'Connell (1991) who found that although 98% of GPs thought it was part of their role to counsel patients with a weight problem most of them found the work dif®cult and unrewarding. One of the reasons why this was the case was that the doctors felt they were not successful in achieving weight loss in their patients (Cade & O'Connell, 1991). Con®rming these ®ndings, our survey indicates that GPs believe they have little in¯uence on weight management. Further work needs to clarify which treatments are the most successful in general practice. Very few GPs reported that they would manage either of the case stories without multidisciplinary support, and partnerships between GPs, practice nurses, dietitians and commercial slimming groups were reported by the GPs in response to each case story. One emerging story was that GPs were more personally active in the case of the overweight female patient set in the context of associated symptoms. This is supported by the reported actions of the GPs in the management of the uncomplicated female overweight patient case story. The case included a greater referral to commercial slimming groups. Further investigation in needed into this observation of different treatments by GPs according to the `medicalisation' of obesity which has had an ICD code since 1948 and was recognised as a

disease by the World Health Organisation in 1998 (WHO, 1998). Commercial slimming groups were noticeably present among the reported professionals involved in treatment of the two case stories. Worldwide evidence suggests that better results are achieved with group approaches than with one-to-one management. But little data from commercial slimming groups has been made available for scienti®c peer review. Thus no measure of ef®cacy of this treatment of obesity or assessment for whom this method is the most effective can be fully made. It also should be recognised that some patients may ®nd these groups threatening (Lean, 1998). Only very weak associations between gender of GP and actions in consultation such as evaluation of psychological problems and taking a full account of weight and dieting history in response to the case stories were found (P < 0.05). These ®ndings were similar to those of Hùlund et al (1997) who found in a sample of 374 GPs in Denmark that in treating overweight people, female GPs paid more attention to dietary counselling and discussion of psychosocial issues. In the present analysis, we sought to examine descriptively the steps that GPs would take in treating an overweight patient. The data presented here is based on selfreported management of two case stories that is GP responses to survey questions about what they would do if this patient presented themself. Information collected in this way may not be a true re¯ection of the actual day-today practices of the GPs working in Scotland but it offers insights into individualised management of contextualised cases. This is likely to provide a more focussed picture of GP nutrition guidance of the overweight compared to previous postal surveys which have elicited responses to the treatment of the generic overweight patient (Cade & O'Connell, 1991). Conclusions This study shows that although the readership of the clinical guidelines in Scotland has been moderate so far a multidisciplinary approach to obesity treatment is recognised. Further investigations of relationships between nutrition education and obesity treatment are needed. Acknowledgements ÐThe views expressed in this paper are those of the authors and are not necessarily those of the sponsor, the Chief Scientist's Of®ce, Scottish Of®ce. The authors wish to express thanks to Marjorie McKenzie of ISD, Scotland, Lyn Middleton, Andrea Shaw and Geoff Cohen at `The Survey Team' Edinburgh, Scotland.

References Cade J & O'Connell S (1991): Management of weight problems and obesity: knowledge, attitudes and current practice of general practitioners Brit. J. Gen. Pract. 41, 147 ± 150. Carstairs V & Morris R (1991): Deprivation and health in Scotland. Aberdeen: Aberdeen University Press. Department of Health (1995): Obesity: reversing the increasing problem of obesity in England. A Report from the Nutrition and Physical Activity Task Force. London: Department of Health. Hiddink GJ, Hautvast JGAJ, van Woerkum CMJ, Fieren CJ, & van't Hof, MA (1995): Nutrition guidance by primary care physicians: perceived barriers and low involvement. Eur. J. Clin. Nutr. 49, 842 ± 851. Hiddink GJ, Hautvast, JGAJ, van Woerkum CMJ, Fieren CJ & van't Hof MA (1997): Driving forces for and barriers to nutrition guidance practices of Dutch primary care physicians. J. Nutr. Educ. 29, 1, 36 ± 41.

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Hùlund U, Thomassen A, Boysen G, Charles P, Eriksen EF, Overvad K, Petersson B, SandstroÈm & Vittrop M (1997): Importance of diet and sex in prevention of coronary artery disease, osterporosis and overweight or underweight: a study of attitudes and practices of Danish primary care physicians. Am. J. Clin. Nutr. 65, 6(Suppl.) S2004 ± S2006. Lean MEJ (1998): Management of obesity and overweight. Medicine 26, 9 ± 14. Royal College of General Practitioners (1980): Of®ce of Population Censuses and Survey Department of Health and Social Security 1981 ± 82 morbidity statistics from general practice London: HMSO.

SIGN Guidelines (1996): Obesity in Scotland: Integrating prevention with weight management. SIGN publication No 8: Edinburgh: Scottish Intercollegiate Guidelines Network (SIGN). Scottish Of®ce (1996): Eating for Health: A Diet Action Plan for Scotland. Edinburgh: HMSO. World Health Organisation (1998): Preventing and managing the global epidemic. Report of a WHO consultation on obesity, Geneva, 3 ± 5 June 1997. Geneva. WHO.