overweight in practice opportunities for gp intervention dr brendan o’ shea lecturer in general...

Overweight in PracticeOpportunities for GP Intervention

Dr Brendan O’ SheaLecturer in General Practice TCD

General Practice Specialty Training & Family Doctor

Childhood Overweight

Can we even ask about it ?

Epidemiology

• Some dreadful figures…..

Leap 2009

Conclusions

Primary care screening + brief counselling did not improveBMI, physical activity, or nutrition in overweight or mildlyobese 5-10 year olds......

and

‘It would be very costly if universally implemented.’

‘These findings are at odds with national policies in countriesincluding the US, UK, and Australia.’

and

LEAP 2009

Only 5-7% of GPs participated.....

• McCallum Z, Wake M, Gerner B, et al. Can Australian general practitioners tackle childhood overweight/obesity? Methods and processes from the LEAP randomized controlled trial. J Paediatr Child Health 2005;41:488–94.

KOALA

• KOALA (Kinder Overweight Activity Lifestyle Actions)• Interventional Study by Mater (Brisbane) on CHOVE• Recruit GPs to case find, and refer to the Study

• Few referrals – 14 (run over18 months) (similar to LEAP)

• eh…..Why ? (Dettori)

‘Oi ! Leave us Koalas outta this ....Obesity - its a Homo Sapiens thing.....’

Dettori & KOALA – Survey of (bold) GPs

‘Only 14 eligible children were identified and referred to the KOALA study by participating GPs – a much lower referral rate than the study required.’

61% reported difficulty broaching the subject39% indicated fear of negative parental response

Dettori, Elliott , Horn; Barriers to management of CHOBE & GP involvement 2009 AFP36(6)

‘Irish GPs’ beliefs & involvement in dietary

counselling in the Primary Care setting in Ireland.’

Survey 247 GPs (58% response rate)

1 in 6 (or 16%) of all consults included dietary guidance

Almost half (44%) indicated they gave dietary advice ‘several times daily’

Most (67%) indicated Practice Nurse routinely gave dietary advice

Most (75%) prescribed anti obesity drugs

Many (52%) indicated having patients who self referred for Bariatric Surgery

2011 Irish Medical Journal, Floyd S, O’ Shea B, Darker C vol 104, no 2.

‘Childhood Obesity in Ireland.Parents fail to recognise, and GPs fail to act.’

Cross sectional GP study, 102 dyads (children 4-14).Questionnaire, consultation, medical record review.

• 16/102 children overweight / obese (CDC criteria); 48 of parents overweight • 81% of parents of overweight children failed to perceived children as

overweight

• Only 1 overweight child had Wt or BMI recorded in the EMR

• 26.7% - 2-3 hours of TV daily and 81 % driven to school

White A, O Brien B, Houlihan T, Darker C & O’ Shea B et al, IMJ 2012 v 5, no 104.

National Survey of GPs on current practice.

20% sample of Irish GPs (n = 527)393 Respondents (80.2% response rate)

Piloted study instrument, based on Dettori.

1(Strongly DISAGREE) 2 3 4(Strongly AGREE) No answer0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

4.07%

16.28%

37.40%

42.24%

0.00%

Childhood overweight is a medical problem (n=393)


5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

50.00%

1.78%

11.45%

41.48%44.78%

0.51%

GPs have a role in childhood overweight management

(n= 393)


10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

27.48%

52.42%

12.98%

6.36%

0.76%

Parents view childhood overweight as a medical problem

1(NEVER) 2 3 4(ALWAYS) No answer0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

9.92%

58.02%

27.48%

3.56%1.02%

Are you routinely measuring children's height / weight ?


5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

32.82%

38.17%

20.87%

5.09%3.05%

Do you routinely use guidelines / standards in this area of practice ?


5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

27.74% 27.48% 27.74%

16.28%

0.76%

Do you use age adjusted BMI charts in identifica-tion of overweight children (n=393)


5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

1.53%

36.13%

39.95%

8.14%

14.25%

When an overweight child presents in consultation, how often do you raise the issue of overweight in

the consultation


10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

9.41%

29.52%

51.15%

9.16%

0.76%

Do you find it difficult broaching the subject of childhood overweight with parents ?


5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

50.00%

7.63%

33.08%

44.27%

14.25%

0.76%

Do you ask overweight children / guardians to return for review of their BMI / weight ?


10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

10.43%

56.74%

22.39%

2.04%

8.40%

How often do overweight children / parents return for review when asked to do so ? (n=

393)


5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

10.94%

21.37%

36.64%

28.24%

2.80%

Modest targeted payments would be effective in management of obese children (n = 393)

Childhood Overweight…

Whatever next ?

GPs clearly conflicted inconsistent poor practice

Childhood Overweight…

Whatever next ?

Lets just do it……lets ask about it !

‘General Practice’ Tom O’ Dowd &Fionn Mc Cann 2012

‘When I see an 11 year old who is 11 stone, I’m tearing my hair out, but telling them they are overweight is difficult. Vulnerable people who are overweight may feel judged if their GP brings it up. I know GPs who have been forthright in their dietary advice, but their Patients have been emotionally traumatised by it.'

Sunday Times Dr Mel Bates Communications Chairman ICGP 2011

“Wealthy obese prefer surgery to better diet…”

Observational study

500 parents and children (5-12 yrs) 10 purposively selected practices (11 GPs) East Leinster areaParents & children serially presenting Invited to participate - parental consent / child assent obtained Children weighed / measured & calculation of BMI

Parents subjected to telephone survey Acceptability 1-2 weeks

Study of Parents / Children on routine weighing and calculation of BMI in practice

Bottom line results from observational study

• 457 (5-12 yr olds) weighed (11 GPs in 10 practices)• 434 dyads completed full survey• Representative sample

How many Parents surveyed felt it was useful to check the weight of their child ?

Bottom line results from observational study

How many Parents surveyed felt it was useful to check the weight of their child ?

98.6% (2013)

Do you believe that having their weight checked by the GP had an impact on the child?

No = 88.9% Yes = 11.1% (Positive Impact 66.7%)

4.4 % of all parents reported negative impact (Upset / Anxious / Angry child)

A few more things......

Of all children recruited (5-12 years)

5-7 year olds least likely to be upset....... Overweight – 1 in 10

Obese – 1 in 411-12 year olds more likely to be upset…..

‘Weighing children.Parents agree, but GPs conflicted.’

O’Shea, Ladewig,Kelly, Reulbach, O’Dowd. Arch Dis Child January 15, 2014 as 10.1136/archdischild-2013-304090

When ? 0……………….12 YearsSample of 1-2 year oldsAttending for last Primary ImmunisationSample of 39 (13 mth olds)

Brief Intervention

Weigh – Objectification of weightSurvey on Eating / Activities

Information Sheet

64% Indicated ‘The Advice encouraged me to improve my child’s health’

Young, Doorley, Darker, O Shea, IMJ 2014.

When ?

• At every consultation – Very / Brief Interventions• Primary Prevention

Prenatal Care Antenatal Care (Activity &

Breastfeeding) 1-2 Yrs and 5-6 Yrs

Education

• ICGP/ROI RCGP Blended Learning Consultation Skills Pack

• 2 Hour CME Module• Blend of evidence / modelled consultations• Suited for individual / group / team learning

Health Service Design

• ROI The Under 6’s / Over 70’s Contract

• Checking weights all of 1-2 and 5-6 year olds

• HSE/ICGP Algorithm, NICE etc

Further Research

Big Fat Fallacy No 29….

People know how to check their own weight ?

Self checking weight….AdultsN = 150 in Farranfore and Kildare 62% Female, 34% BMI 25-30, 30% BMI >30.

28 % Have no scales26% Indicate they never check weight11% Indicate weighing yearly59% Indicate ‘No Routine’ for checking their own weight

They think in Stones and lbs….We think in terms of BMI and Kilograms….

Cat No 2556748 B, page 78

The Holy Grail

• Stabilisation of prevalence of childhood overweight (Denmark, Switzerland, US cities)

Sooner….or….Later ?

It depends on you and I…

Advanced Practice

• Screening and coding for overweight (100%)• Brief Interventions & Managed Care• Local Resources• Learning Material (Professionals/ Public)• Modest Funding (very) to direct activities• Embedded in vigorously healthy environment• Leadership – Personal / Policy / Political

In the Advanced Practice• High quality EMR, with built in tools• Practice Weight Champions• Congratulate the majority• Support and direct the Overweight Crowd• Learning Materials & Weighing Stations• On site resources (‘Weight Champion’)• Good secondary care referral resources• Uniform / Systematic / Opt Out• Many High Five Moments….

Before Fat and Globesity….

• War• Famine• Bubonic Plague• Syphilis• Tuberculosis• HIV• Swine Flu• Tobacco

Thanks for listening

Qs and As ?

overweight in practice opportunities for gp intervention dr brendan o’ shea lecturer in general...

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