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Independents' Day

Time to drop the ‘tough love’ stance on obesity

Dr Zoe Norris

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I saw a patient today. BMI of 41. What’s the first thing that springs to mind?

Fat. Lazy. Brought it on themselves. Of course no GP would say this, yet we are encouraged to address weight issues with brief interventions in appointments. But who is comfortable with doing even this?

We’re all used to the standard patter for smokers: if we’re feeling all MRCGP, we ask ‘is there anything I can do to help you stop smoking?’ If we feel more realistic, it’s ‘you’re still smoking?’ with a disapproving frown.

Yet with obese patients it’s somehow more awkward. You don’t want to cause offence, but it’s just as important as smoking. What will pointing out their weight achieve? I doubt any obese patient doesn’t realise it’s an issue; I haven’t had anyone gasp in disbelief and say ‘Really, doc? Being 22 stone isn’t good for me?’ Of course they know, and their weight has probably been a daily focus for years.

I can count on one hand the patients who've lost lots of weight through diet and exercise

So we need to ask: what should GPs’ role be? Should we follow a ‘tough love’ approach, and does our own weight affect how we deal with obese patients? Gosh, I’m starting to sound like an actual doctor!

I’ll spend the whole consultation about hypertension or knee pain wondering how to say ‘it’s your weight’. Then I’ll cop out or end up half-heartedly muttering about eating less and moving more, knowing from the look I get that it’s not news to them and not to bother asking for 360° feedback.

I’ve come to realise I’m pretty badly informed about obesity. I haven’t understood how it changes the way the body regulates itself, or considered the complex emotional elements. I should exercise more, eat less, drink less – so why don’t I? Why don’t all doctors, since we’re held to a higher standard than mere mortals?

I don’t feel I can preach to patients about the merits of daily runs and kale smoothies when I’d rather watch Lucifer with a glass of wine and a large bar of Galaxy caramel. And with the risk factors many face – deprivation, disability, certain ethnic backgrounds – it’s easy to imagine that one day you realise being a bit overweight has become obesity and the way back feels like an impossible uphill climb.

I can count on one hand the patients who’ve lost vast amounts of weight through diet and exercise. We don’t expect all smokers to give up instantly, so why do we think these patients can just decide to lose weight and achieve it?

We are getting better at looking at the wider picture. We recognise obesity often starts in childhood, that parents have a key role to play and that early intervention is better. Some patients may also have the complex emotional baggage that often accompanies obesity, so being told to exercise more and eat less is like telling an anorexic patient to eat more, or a drug addict to just stop using.

This may actually be one occasion when we do need to don our CSA hat. We need to ask and listen, put our own bias and judgements aside, and be a bit kinder to obese patients, and colleagues. Next time you see a patient whose BMI is high, or hear a fat-shaming comment, spare a second to think how it must feel. Do a bit of reading about it, and maybe think when you last did some exercise or said no to that biscuit with your coffee.

Dr Zoe Norris is a GP in Hull

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Readers' comments (10)

  • We certainly do need to look at the bigger picture - mainly the incorrect cietary advice that's been dished out by government (and us) for over 30 yrs now. Dietary fat is not the issue, there's absolutely no evidence to support low fat,calorie restricted diets. The problem is INSULIN and the carbohydrate (refined or otherwise) that drives its secretion.
    There is also no evidence that exercise (aka moving more) leads to weight loss. Exercise is good for all sorts of reasons, but unfortunately losing weight isn't one of them.
    A low carb, ketogenic diet is the correct advice to give and in my view government and PHE need to get on board with the mouinting levels of evidence which support this approach.

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  • There is insufficient evidence of long term benefit to justify advising patients to sign up to ANY slimming diet cult and I find it distressing that our local NHS is in bed with a commercial slimming organisation. I advise patients that my responsibility is to secure the best medical care for them irrespective of their body size. In those of middle years and beyond, the risks of frailty and sarcopenia worry me far more than obesity.

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  • Would write something but Stephen just said it all. Agree

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  • I agree with all the comments so far - and I feel especially uncomfortable about the NHS goind to bed with Slimming World and Weight Watchers.

    But Zoe- if we all adopt a very lifestyle approach to consulting, we would feel no more embarrassed about discussing the contribution of weight to back pain and OA, as we would if we discussed the role played by diet in constipation and dyspepsia.

    The answer lies in facilitating patient behaviour change for all things, rather than reaching for an FP10

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  • Knowledge is Porridge

    There is a huge desire (dare I say appetite) for losing weight, but the fat ones are rubbish at it. But they can change.
    Having seen lowly parkrun transforming lives, I haven't given up on obesity yet.
    Being a partner, having your own list, knowing the patient, the family and community, Its a massive opportunity to help.
    Obesity is an issue worth getting excited about in GP.
    Dr David Unwin has shown the way

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  • It’s a frustrating but fascinating subject. Exercise is a double edged sword- in some people it triggers a radical overhaul of their health, some people see it as a get out of jail free card for eating anything they like. And it does seem a diet based on vegetables, fats and natural protein sources is best for us but the only way of supporting the world population we have is through cereal crops- population increases have only been possible with the industrialisation of wheat production. And I disagree about slimming world and weight watchers- evidence says they do a better job than nhs weight loss programs

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  • Also there is association with childhood sexual abuse and extreme obesity. The BBC did an article about this the other day and I was already aware of it with my own patients, to the extent that if I see a young woman with extreme obesity I automatically assume, maybe wrongly,that there is a back story like this. In middle aged people with "normal" obesity we've had some fantastic exeriences from the Slimming world and gym prescription initiatives. So much better than telling people to lose weight, as if they didn't already know, then getting a 5 page letter of complaint.

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  • I agree with considering the bigger picture - but for me that includes the obesogenic environment. Lots of scope for regulation & legislation, and I think medical profession should be encouraging those changes to be made.

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  • When I was an appraiser, I had two GPs who’d had complaints from patients about “opportunistic health interventions” about their weight. Both of them had given up mentioning it. They said there’s enough public information out there from any number of sources, so that people cannot be in any doubt that flab is bad.
    Back in the day, we knew our patients well enough to put that virtual arm around the shoulder and discuss sensitive issues like this. Nowadays, we are just some strange doc that they’ve never seen before “telling” them that they’re fat.

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  • anon2016 very wise words. I’ve known some GPs put it less than sensitively however

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