A large proportion of the population is overweight. What role should the GP play vis-à-vis patients who want to lose weight?
In a qualitative study published in this edition of the Journal of the Norwegian Medical Association, Juvik et al. describe the experiences of people with overweight in consultations with their GP (1). The informants who were interviewed felt that weight was a 'non-topic' in the doctor's office, and called for doctors to initiate a conversation about weight, even in consultations to discuss other health issues. They also wanted their GP to function as a 'wake-up call' and viewed them as an important source of support in the fight to lose weight.
The study is consistent with other research showing how doctors can be unsure about how best to talk about overweight. Weight problems are a sensitive topic for many and are associated with stigma. The patient-centred method recommends that doctors ask for permission to discuss sensitive topics (2). This can be kept simple by using neutral language that relates to the patient's medical history: 'Is it okay for me to ask you about your weight? Has it been stable or changed over time?' Where the patient talks about weight gain, the doctor can explore whether the patient has concerns about their weight and clarify the reason for this and whether they want help (3).
The study is consistent with other research showing how doctors can be unsure about how best to talk about overweight
Early detection of disease is something that is close to the GP's heart, and case finding is an important part of the GP's work (2). When a GP discovers that a patient is at risk of developing a health problem, it is natural to discuss preventive measures during the consultation. GPs report discussing preventive measures thoroughly with the patients in 13 % of consultations (4), while 38 % of consultations include general preventive efforts (5).
What role and responsibility should GPs have vis-à-vis patients with overweight when this has become the new normal? Seven in ten Norwegians are overweight, and one in five are obese (1). For healthy people, it is primarily obesity that is associated with increased health risks, and that is within the GP's mandate for case finding. Both the GP regulations and national guidelines advise against opportunistic screening, and risk factors should primarily be assessed where it is relevant to the clinical issue (6).
One of the main principles of the regular GP scheme is that it is openly accessible. Patients book appointments themselves for health issues they want to discuss. The typical Norwegian visits their GP two to three times a year and normally addresses two different issues in each consultation (4, 5). The GP must decide in each consultation how to prioritise the amount of time spent on preventive work. The GP's remit is primarily to address the issue raised by the patient.
Individual prevention is resource-intensive, and clinical guidelines underestimate how much time doctors spend on such measures. The time needed by clinicians to treat patients was therefore recently introduced as a concept in the guidelines (7).
Being labeled as 'at risk' is also associated with negative health repercussions and is problematic from an ethical perspective if the patient has not requested a risk assessment
An interesting finding from the study is the wish for GPs to assume an authoritarian role in providing a 'wake-up call', where the doctor makes patients aware that they are at risk. This is thought-provoking, as the desired development has been for doctors to distance themselves from a paternalistic medical role. Previous research has pointed to the GP's ability to use 'golden moments' as a gentle way of raising patients' awareness (8). Spotting the connection between health problems and overweight can help individuals to take action and mobilise resources. Paternalistic methods and scaremongering can violate vulnerable people and lead to disempowerment, especially where obesity has occurred in the aftermath of painful life events (9). Being labeled as 'at risk' is also associated with negative health repercussions and is problematic from an ethical perspective if the patient has not requested a risk assessment (8).
Overweight is a public health problem that requires population strategies. Society must help to make it easier for people to make healthy choices. The two main factors that influence what we eat are access to food and price, and our environment determines how much we move. A safe and secure childhood that promotes activity is a good place to start, and this should be followed up with implementation of the political promise of one hour of daily physical activity for all schoolchildren. Public health efforts must focus on kilometres, not just kilograms.