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The big, bad obesity pandemic

The Department of Health regards obesity as a ‘public health priority’, but three years on from the publication of the Government’s action plan, what progress has been made? David Lynch reports

The Department of Health launched A Healthy Weight for Ireland: Obesity Policy and Action Plan 2016-2025 in September 2016, and since then, a series of initiatives have begun.

Last November the Minister for Health Simon Harris said obesity — and especially child obesity — was among “the most serious issues” faced by the country and the health service.

However, the person appointed as HSE Clinical Lead for Obesity in 2017 believes there is a major challenge in making the action plan work. The challenge is funding.

“Look, it’s absolutely essential,” said Prof Donal O’Shea, Consultant Endocrinologist and Physician in St Vincent’s University Hospital and St Columcille’s Hospital, Dublin, who is also HSE Clinical Lead for Obesity.

“There has been effectively no sustained funding allocated to deliver on the actions in it yet,” he told the Medical Independent (MI).

“We submitted to the estimates process last year and got nothing for the treatment of obesity. We are re-submitting to the estimates process this year, and I think it is fair to say that if there is nothing given, then the obesity policy and action plan, in a meaningful way, is not going to impact on individuals living with obesity.”

Bariatric surgery

According to Prof O’Shea, much of the required investment should fund more bariatric surgery, which he highlights as currently at a low level in Ireland compared to countries like Canada and France.

Early last year, in a previous interview with this newspaper, Prof O’Shea warned that he “won’t hang around” in the clinical lead post if sufficient funding is not provided for obesity-related measures.

More than a year on, does this warning still hold?

“I think if there is nothing in the Budget again this year, then I would have to sit down and have a think, because it will be three years since the launch [of the action plan],” said Prof O’Shea.

“And if you fail to secure funding to back even the beginnings of a treatment programme… and if you’re not even on the first step of the ladder, then you would have to say, ‘do I need to pass this over to somebody else to lead the agitation for funding and support them in their battle?’”

Some of the high-profile initiatives in recent years include the Sugar-Sweetened Drinks Tax (SSDT) introduced in May 2018. However, concerns have been expressed that the revenue raised is not ring-fenced.

“You know, the €30-plus million or thereabouts raised in the sugar tax, if you were looking at establishing robust [obesity] treatment programmes in Saolta or Ireland East [Hospital Groups], just €4 million would have you comfortably up and running and providing more access to treatment than we have ever had before,” said Prof O’Shea.

“That €4 million would start saving us money, because the cost savings of doing this procedure are very clear to the health service.

“It is new revenue to the exchequer, so why is it not being put in part towards providing treatment to people living with obesity and to help in the prevention of obesity? I don’t understand it.

“The College of Physicians [RCPI] have asked for it, the Irish Heart Foundation, and others, have asked. Use the money sensibly. Don’t just pour it into servicing the national debt.”

An idea currently floating in public health circles in the UK is the possible introduction of plain packaging for sweet products. It is something that has interested Prof O’Shea, but “I think there is very little appetite amongst the [Irish] political system [for it]”, he said.

“Public Health England has called for that. I think it’s a very good idea… industry will oppose that tooth-and-nail, because that is their job. But it is our job to say, ‘look, we are in the middle of an obesity pandemic, so you have got to think outside the box’.”

Education

Obesity education and training for health professionals is “possibly the most important measure at this point”, according to Dr Grace O’Malley, Division of Population Health Sciences, RCSI, and Multidisciplinary Team Clinical Lead, W82GO Child and Adolescent Weight Management Service at Children’s Health Ireland, Temple Street.

“If health professionals are better prepared, they can in turn educate and learn from patients.

“Bit-by-bit, we will then come to understand the significant changes that are needed at a societal level to manage and prevent obesity,” Dr O’Malley told MI.

“Changes like regulating marketing of edible products to children, optimising the quality of food within the food system, improving the built environment, optimising our health system and addressing inequality will not be possible without a clear mandate from a significant proportion of our population.

“I don’t believe we will demand that shift in society without first improving our knowledge and understanding of how the environment in which we live and the overarching economic policy impacts upon our health.

“As citizens, we have a right to ensure the health of our communities but misinformation and confusion may be focusing the debate on personal responsibility rather than disentangling the need for self-care at an individual level from the responsibility of Government and policy at a society level.”

GPs

Government policy, particularly as outlined in the Sláintecare Report, envisions general practice taking a greater role in chronic healthcare — including obesity.

Dr O’Malley said that best practice guidelines recommends a stepped-care approach “where appropriate obesity interventions are offered to patients based on the severity of their disease, which is determined through clinical assessment and monitoring”.

“Similar to other chronic diseases, the primary care setting is essential in this paradigm and the role of the GP cannot be understated.

“It is vital, though, that training is optimised so that GPs are aware of the contemporary evidence-based treatments and feel confident offering them.

“I believe we need a discussion around whether we understand primary care practitioners to be solely GPs and practice nurses, or whether the Irish definition includes public health nurses, area medical officers, dietitians, physiotherapists and psychologists working in primary care.

“Clarity regarding this is essential, as the appropriate treatment for obesity needs to be delivered which, depending on severity, might range from a brief intervention by a practice nurse, to a multi-component intervention delivered by the GP, a dietitian, physiotherapist and psychologist, ideally working in synergy.

“If treatment is being delivered by the GP, the Department of Health and the HSE need to understand that the chronic care model must be applied and appropriate reimbursement for the appropriate treatment should be assured.

“Similarly, if primary care is to deliver the bulk of childhood obesity treatment, obesity should be included in the integrated model of care for paediatrics so that there is a clear pathway of care for these children.”

Contract

The GP contract recently agreed between the IMO and the Department of Health includes the introduction of chronic disease management for three named diseases — chronic obstructive pulmonary disease (COPD), diabetes and cardiovascular disease [see sidebar].

While obesity is not specifically named, it will have an impact in this work, said Longford GP and IMO President Dr Padraig McGarry.

“We have agreed a chronic disease programme which comprises specific clinical and laboratory assessments for certain individuals… and for certain named conditions,” said Dr McGarry.

“That would involve two doctors’ and two nurses’ visits per annum. Now, obviously when it comes to managing these conditions, medication is part of it, but lifestyle issues would be very much to the fore of managing these issues as well.

“So I mean, the lifestyle issues would be smoking, dietary, alcohol, exercise and weight management programmes. Currently, that would be part and parcel of any advice you are going to give a patient with the conditions outlined here. That would remain as such.

“But I suppose what is happening with the chronic disease programmes, especially with the likes of diabetes, we are now forming a more structured approach to it, whereas before [the new contract] it was more on an ad-hoc basis.

“Certainly, advice on diet and exercise regarding obesity is central to all that.

“But we would be expecting in those situations that we would obviously be giving some verbal advice, literature advice and we would also be referring on [patients] to some support services in the community which are run by the HSE for the likes of smoking cessation, weight management and exercise.”

However, while agreeing that general practice has a crucial role in providing care for people with obesity, Dr McGarry said this was a challenge that needed a wider-based solution.

“We [GPs] would be dealing with patients who are morbidly obese, etc,” Dr McGarry told MI. “But the whole issue of obesity needs to be dealt with at a more fundamental level, and at an earlier stage.

“Almost when we are seeing them [patients], the horse has nearly bolted. We need to be dealing with it from the perspective of children, even pre-school children, and that should come through the public health interventions, educational interventions, and from pre-school interventions and parents.

“Because in the long-term, if we are going to try and get ahead of this, it has to start at the very early stage. Once the condition has occurred, then you have missed that boat, really.

“We would see the management of the obesity crisis as an overall approach. That is the longer game, but that longer game has to take place as well.”

Doctors’ knowledge

In terms of doctors’ knowledge of obesity, Prof O’Shea said “there is some improvement”.

“GPs are certainly more signed-up to the concept of obesity as a disease, thankfully. But patients living with obesity still experience massive discrimination, with many healthcare professionals still feeling it’s their fault, and if they took responsibility and if they simply ate less and moved more, they would lose weight.

“We know that isn’t the case. Eating less and moving more is the prevention strategy, but once you are living with obesity, ‘eat less move more’ is not the treatment.  Like, stop smoking is the way to prevent lung cancer, but once you have your lung cancer you need that treated…” according to Prof O’Shea.

On the issue of doctor awareness, Dr O’Malley said she could “not answer this with certainty, as to my knowledge, this question has not been explored systematically in Irish doctors to date.”

“From my own experience working in the area, I do not believe that obesity is understood as a disease by most Irish health professionals, including doctors, even though it was classified as such by the WHO in 1979,” said Dr O’Malley.

“Most doctors were, and unfortunately still are, taught very little about obesity during their training and instead often hold the belief that weight regulation is under the conscious control of the individual.

“Though we can certainly make active choices around lifestyle, we now know that for some people with a higher genetic load, it will be very difficult to avoid weight gain and once gained, reducing weight and maintaining weight loss will be extremely difficult.

“A lack of understanding by health professionals at this point can have negative effects on patient care, as weight-bias and stigma are very common and disempower patients. Based on the scientific evidence, obesity is recognised as a chronic, progressive, relapsing disease but it’s essential that we are all speaking about the same thing when we use the term ‘obesity’.”

Dr O’Malley said a key misunderstanding is due to the fact that “we use body mass index (BMI) as a surrogate measure of adiposity to classify obesity”.

“BMI is easy to calculate and is a simple tool that indicates body size, but gives no information regarding body composition.

“So although a person may have a BMI that suggests obesity, only when we determine that excess adipose tissue is interfering with physical and/or psychological function can we truly give a clinical diagnosis of obesity.”

In terms of the general challenge of obesity, Dr O’Malley said: “The argument is often made that prevention should be prioritised over treatment, but we can learn from how we addressed HIV/AIDS. Initially, the focus was on prevention but over time, we came to understand that prevention, treatment, care and stigma-reduction were all essential components to successfully managing HIV. We have to learn from previous pandemics.”

Dr O’Malley recommended doctors should contact the professional bodies and the HSE for training and education needs regarding obesity and attend the European and International Congress on Obesity to be held in Dublin next year.

Getting with the programme on chronic diseases

As part of the new GP contract, there will be chronic disease management systems established for chronic obstructive pulmonary disease (COPD), diabetes and cardiovascular disease.

According to the IMO, €80 million will be provided to support the phased introduction of this care for GMS patients.

The phased introduction is due to start early next year, and by 2024, over 400,000 GMS/Doctor Visit Card patients will be in a chronic disease programme or a high-risk evaluation scheme.

“What has happened in the past is that GPs would look after patients with these conditions in an ad-hoc sort of way; there was no real structure to it,” Dr McGarry told MI.

“But we have formulated here a more structured approach to it, specific clinical and laboratory assessment made, advice given to patients at the end of each visit. There would [also] be a data return whereby the HSE would receive information about it.”

Obesity care will also play a role in this, however it will be up to individual GPs whether they want to sign-up to the chronic management system.

“The onus is on the GP to decide whether that is suitable for their practice or not, whether they have the manpower to do it, whether they have the time to do that,” said Dr McGarry.

“With these cohorts of patients, especially the more elderly [and] the multimorbidity patients, these patients tend to consult a lot. What we are hoping is that we might replace all those consultations that currently exist, into those structured consultations, which we have agreed. 

“Hopefully that will mitigate the resource requirements and the time perspective… Hopefully it won’t have the effect of putting a strain on general practice.

“But that is for every GP to decide themselves; it is an opt-in thing.”

Obesity facts and figures

*  Just under four-in-10 (37 per cent) of people have a normal weight, six out of 10 (37 per cent overweight and a further 23 per cent obese) are overweight or obese.

*   Whilst men are more likely to be overweight than women (men: 43 per cent, women: 31 per cent), the proportions that are obese are more closely aligned (men: 25 per cent, women: 22 per cent).

*   31 per cent of men aged 15-to-24 are overweight or obese, compared to 27 per cent of women of this age.

Source: Healthy Ireland Survey 2016

*   15 per cent of young people under 24 drink sugar-sweetened drinks daily.

*   34 per cent of people consume at least one unhealthy food item daily.

Source: Healthy Ireland Survey 2018

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