European GPs feel inadequately trained to prevent and treat obesity. Should we care?
A recent survey of European GPs indicates that they are not confident in managing obesity, and are too short of time during sessions with patients to go into any detail anyway, with only 10 minutes spent on each patient on average. GPs recognise that obesity is a complex issue, but are overwhelmed by their workload. Ironically much of this is obesity, diet and lifestyle related, and therefore much of it is largely preventable.
GPs are calling for more training on obesity, but also feel that the public needs more education on the causes and consequences of it. 97% of U.K. GPs felt that there should be more education of the public on these topics. I wonder what the remaining 3% were thinking? There is a feeling amongst European GPs that people are becoming more complacent about the negative health effects of obesity. This is probably largely due to the fact that it has become so normal and normalised in society. However, GPs feel that obesity ranks among the top five most serious dangers to health, with type 2 diabetes being one of the most important complications (it may be more accurate to say associations, as it is more likely that the biochemical abnormalities causing both type 2 diabetes and obesity are the same, and it is possible to have type 2 diabetes without obesity, as well as insulin-sensitive obese individuals). Less than half of the GPs interviewed in this survey felt that their peers provide effective advice on losing weight and overcoming obesity. To be quite frank, I’m surprised the numbers were as high as this. Obesity is not managed well in health services, and in the U.K. the majority of GPs have had less than 4 hours training in the causes, consequences and treatment of obesity.
Credit Suisse also published findings from their surveys of doctors and consumers in the publication, Fat: The New Health Paradigm. Their findings support that most doctors still believe, despite evidence to the contrary, that low fat diets are better for health, more than 80% of doctors believe that saturated fats and trans fats are linked to obesity, and more than 89% believed that both were linked to cardiovascular disease. 54% of doctors also still believe that eating cholesterol-rich foods raises blood cholesterol, and that cholesterol-rich foods are not good for the heart (despite the fact that these myths were debunked many years ago). Incredibly most doctors also believed that butter was less healthy than margarine!
The vast majority of GPs recognise that prevention of obesity should be a priority, and almost as many would like to see better treatments for it. However, most GPs feel that personal responsibility for managing their own weight should rest on patients. Does this reflect a blame culture, where unscientific dietary guidelines are being let off the hook, yet again? Worryingly, in the UK only 59% of GPs feel that healthcare professions need to play bigger roles in preventing obesity. This strikes me as ironic, given that non-communicable diseases have reached epidemic levels, are now the world's biggest killers, accounting for 63% of global deaths, and 89% of total deaths in the U.K. and the greatest drain on money and resources on the NHS, which is actually buckling under the weight of non-communicable disease. A few years ago, in 2012, it was estimated that the UK government was spending £6 billion on direct medical costs related to overweight and obesity, equivalent to 5% of the NHS budget. This was estimated to double by 2030, if trends continued.
The attitude of GPs to things like vaccine-preventable illness is very different, where they believe there is a role for healthcare services in public health. The same goes for smoking cessation, and the Royal College of General Practitioners recently released a statement that services to help patients stop smoking should be available to all patients who could benefit from them throughout the U.K. It also differs when it comes to prescribing medications for alleged risk factors for ill health, like statins for high cholesterol, blood pressure medications and anti-diabetic drugs for type 2 diabetes, all of which have marginal benefits in terms of life expectancy, while carrying significant risks. And these risk factors and diseases, seen in older people, are invariably linked with diabetes.
Have GPs inadvertently stopped prioritising the health and well-being of their patients under the influence of the pharmaceutical industry, and turned to targeting surrogate markers of health that can be managed with drugs, without looking at the real life outcomes for patients in terms of how they are feeling, and how long they survive? Or are the influences of the pharmaceutical and food industries in altering attitudes of doctors more indirect, by hijacking the evidence based medicine movement, diverting attention away from real outcomes and more towards chasing surrogate endpoints in trials, and all the other tricks in their playbook, while infiltrating guidelines committees and steering committees in order to produce guidelines that benefit them? Much has been published about individual and institutionalised corruption in medicine and healthcare, but how do these effects trickle down through institutions and systems and impact upon practicing clinicians who are not themselves corrupt, and on their patients? Dr Peter Wilmshurst, the now infamous cardiologist whistleblower, presented evidence on research misconduct to the U.K. Parliament House Of Commons Science and Technology Committee in April 2017 during an inquiry into the integrity of medical research. What he said was very damning, and it is well worth reading his written evidence. Dr Aseem Malhotra, consultant cardiologist, announced that it is his belief that honest doctors can no longer practice honest medicine during his presentation on Killing For Profit at the European Parliament in April 2018.
Could GP attitudes towards diet and lifestyle treatments simply be a reflection of patient expectations (since many patients perceive doctors as pill pushers with a prescription pad; while the demand, day in, day out, for more pills to manage symptoms and risk factors in the hope that this will stave off disease, becomes ever greater) rubbing off on GPs, who now feel that pharmaceuticals are all they can offer? Is it simply that GPs feel so completely overstretched at present that they cannot contemplate the thought of having anything else added to their plate, and are barely coping with putting out the fires that are already lit? Could it be that the failure of obesity clinics and weight loss programs to actually manage obesity results in GPs who believe that attempting to do so is an exercise in futility and a waste of time? No matter the cause, only 10% of UK GPs thought that they should play a bigger role in preventing obesity, despite the fact that obesity-related conditions are one of the reasons they are so overworked.
Having said this, the prevalence of obesity within the U.K. is the highest in Western Europe, with more than a quarter of the adult population now being obese. Clearly the management and prevention of obesity shouldn't be shouldered entirely by GPs and other healthcare professionals: The issue is a public health one. In fact there are concerns that the obesity epidemic began shortly after government guidelines in the USA first recommended low fat high carbohydrate diets based upon an unproven theory that fats, saturated fat and cholesterol cause heart disease. Unfortunately, it appears that the government dietary guidelines committees are likely to continue to propagate low fat high carbohydrate dietary guidelines in the U.K. under the auspices of the Scientific Advisory Committee on Nutrition (SACN), who have recently gone out of their way to manipulate the presentation of the scientific literature on dietary saturated fat, while giving it a thin veneer of officiousness. Thankfully, Dr Zoë Harcombe, in a Herculean display of valour, critiqued the scientific method of SACN, and also highlighted their remarkable conflicts of interest. She went through the document with a fine tooth comb and highlighted all of its errors. However, the responsibility of the UK government and Public Health to lead does not mean that GPs and other health professionals should completely wash their hands of the growing obesity epidemic.
Fewer U.K. GPs will initiate discussions about a patient’s weight than other European GPs. Is this a reflection of cultural taboos and the risk of offending, clinic slots being too short, or being overwhelmed due to being more overworked and underfunded than in other countries?
The UK also had the lowest numbers of GPs who view obesity as a disease out of all the European countries, despite all the evidence that has accumulated on how mitochondrial dysfunction, oxidative stress, and chronic inflammation, as well as hormone dysregulation, tie in with obesity. This may be a consequence of the very poor obesity training in the UK, and may be another factor explaining why UK GPs feel that they should not be the ones helping to prevent obesity. If they often do not view it as a disease process, how do they view it? A social problem? Laziness? Sudden widespread moral turpitude with onset after dietary guidelines were brought in? Someone else’s problem?
However, how do these judgments actually tie in with obesity trends, to which health professionals themselves are not immune? In the 1960s rates of obesity in the U.K. were estimated to be only 1-2%, but this had increased to 26.9% by 2014. There have been multiple behavioural, dietary and lifestyle changes, as well as changes in exposure to environmental toxicity in the intervening five decades, but does this mean that human personalities have altered massively at the same time? It is certainly true that our consumption of processed, fake foods has increased dramatically since the 1960s, with ultra-processed foods now making up just over half of all U.K. food purchases in 2008. Unprocessed and minimally processed foods only accounted for 28.6% of the food available to U.K. households in the same year, and the trend in ultra-processed food consumption has not yet shown any signs of turning around. The reasons for this are complex, but include;
- more women being employed full or part-time. But there remains unequal division of chores within many households, meaning that frequently the responsibility for feeding the family falls to mothers who are working full-time, while trying to also do more than half of the cooking, cleaning, and child care. This leaves less time available for parents and other adults to cook nutritious meals from scratch.
- low fat government guidelines ushered in a new era of processed and ultra-processed foods to replace foods naturally higher in saturated fats, cholesterol and total fats. Since naturally occurring fats impart a great deal of flavour, differences in mouth feel and texture, different aromas, and other characteristics which make foods more desirable, the food industry responded by increasing the amount of refined carbohydrates, especially sugar, white flour and starches, flavour enhancers, artificial sweeteners, colourings, emulsifiers and, in order to extend shelf life, preservatives were also added. Simultaneously, many nutrient dense foods were reduced or replaced; particularly red meat, organ meats and eggs, while choices of fats changed from traditional fats, such as lard, drippings, tallow and butter, to highly refined, rancid vegetable oils and margarine. These changes conspired to increase the intake of foods which were energy dense and nutrient poor, containing more toxins and less vitamins, minerals and antioxidants.
- the prices of many commodities also fell dramatically, making the availability of treats far greater, until they have become an everyday occurrence, instead of occasional.
- availability of cars, public transport, kitchen appliances, and machinery means that we do not have to walk as far, or do as much physical activity in the house and garden, or in agriculture and other jobs. Does this make us lazy, or just privileged? However, a surprising recent study looking at the total energy expenditure of the Hadza (traditional Hunter-Gatherers who still live much like their ancestors have done for millennia) showed that they did not expend more total energy than Westerners, which challenges conventional views that our contemporary human brothers and sisters around the globe are much less active than their ancestors.
- obesity is well documented as being associated with fatigue and sleep disturbances, and heat intolerance, as well as depression, which should come as no surprise, given the association with mitochondrial dysfunction, thyroid dysfunction, and inflammation. Many overweight and obese individuals are also prescribed medications that could interfere with physical activity, like statins. Do these complications alter how much activity obese individuals can comfortably perform, and how much they feel motivated to do? It seems likely that they would.
- obese individuals are frequently prescribed multiple medications, some of which have weight gain as a side effect. Is it fair to place all of the responsibility of weight management on the patient, when prescription medications are often a part of the problem?
- targeted advertising of ultra-processed foods to children, adolescents and ethnic minorities may be particularly effective at creating behaviours tied in with increased consumption of junk foods.
Unfortunately, despite the fact that there is now an immense body of evidence showing that, although exercise has many benefits ranging from improved cardiovascular health, to better mental health, to greater bone density, weight loss is not one of them. However European GPs still believe that lack of exercise is the commonest cause of obesity. At this point I would like to remind you of all the spin created by the food industry to promote weight loss by increasing calories burned through exercise in order to protect sales of their sugar sweetened beverages. It seems that GPs are no more immune to this propaganda than the rest of us, and the junk food industry can mark this myth down as a win.
Diet and exercise are the first line recommended treatments in most European countries, although bariatric surgery is also an important available treatment, particularly in France and the Netherlands, where it may be more readily available than diet planning support and exercise. The U.K. prescribes medications in general practice much more frequently to treat obesity than other European countries. CBT and herbs are not recommended frequently by GPs, apart from in the Netherlands, where CBT is commonly offered.
There is a real halo effect around bariatric surgery, with most GPs believing that it is the most effective treatment for obesity. Clearly dietary guidelines have been a failure in managing and preventing obesity, but from this survey it is hard to discern whether GPs are questioning whether or not the guidelines are scientific, or whether they believe that people have suddenly become weak willed and are disobeying dietary guidelines over the past few decades. It seems more likely to be the latter, since more than half of U.K. GPs believe that people with obesity lack the willpower to lose weight, while about a third believe that people with obesity regain weight because they are lazy and have stopped trying to manage it.
What are your views on this report? Are you a GP or in healthcare? Are you a nutritionist or dietitian? Have you ever battled obesity yourself, or have you always been effortlessly slim? Have you been successful managing your weight using exercise alone, but eating mostly ultra-processed foods, high in refined carbohydrates, industrial vegetable oils and food additives? Would you like your doctor to provide more support in managing and preventing obesity, and if so what would you like to see them change?
The full report can be found here.
If you would like evidence based support in improving your health, you can contact me at http://www.thefoodphoenix.com/