Dutch General Practitioners’ weight management policy for overweight and obese patients

Overweight and obesity constitute a global problem, denoted by the World Health Organization (WHO) as “globesity”. In 2008, 35% of the adults worldwide were overweight, defined as a Body Mass Index (BMI) of 25.0-30.0 kg/m² and additionally 12% of the adults were obese, defined as a BMI ≥ 30.0 kg/m² [1]. The number of people with overweight and obesity has increased rapidly in recent decades. In the Netherlands alone, the prevalence of adults with overweight increased from 28.2% to 36.8% between 1981 and 2011. In addition, the prevalence of obesity doubled from 5.3% to 11.4% during the same period [2]. Without preventive action it is estimated that overweight and obesity in the Netherlands may affect two thirds of the adult population by 2024 [3]. As a consequence, Dutch healthcare costs directly related to overweight and obesity are substantial [4]. Overweight and obesity are important risk factors for chronic diseases like Type 2 Diabetes Mellitus, cardiovascular diseases, different types of cancer (endometrial, breast, colon) osteoarthritis [5] and are related to poorer quality of life [6]. In addition, obesity is significantly associated with major depressive disorders and anxiety disorders [7].

As gatekeepers in the Dutch health care system, General Practitioners (GPs) can play an important role in both the prevention and management of overweight and obesity. Nearly 80% of all Dutch citizens visit their GP at least once a year [8]. People with obesity consult their GP more often than those without obesity [9]. Guidelines for GPs’ weight management policy are outlined in the Obesity Standard of the Dutch College of General Practitioners (NHG). Diagnostics and treatment are indicated for patients with a BMI ≥ 25.0 kg/m², weight-related comorbidities or increased cardiovascular risks. For overweight patients with an excessive waist circumference, diagnostics and treatment are only indicated if weight is the patient’s reason for consultation. Treatment may consist of counseling about nutrition, physical exercise, motivation, and discussion about environmental influences, psychosocial problems and weight-related health risks [10]. Referral to other health care providers (i.e. dietitian or nurse practitioner) is indicated in the following situations: if requested by the patient, if underlying causes such as psychological problems are suspected, if previous attempts to lose weight have failed or if the patient needs comprehensive support [10].

Previous studies have shown that GPs intervene in terms of diagnostics and treatment in only half of the patients with obesity, but specific information about The Netherlands is missing [11, 12]. Barriers among GPs to discussing weight with their patients were a lack of time, insufficient knowledge, inadequate skills, lack of confidence and insufficient motivation among patients [13–20]. Female doctors were more likely to deliver weight-related counseling and were more prevention orientated in obesity management compared to their male colleagues [21]. Also GPs’ age has been shown to be related to their attitude regarding weight management policy, although results are inconsistent [22, 23]. Finally, GPs who themselves were conscious of their personal diet, appeared to calculate patients’ BMI more frequently [14].

With regard to the referral percentage of patients with obesity for nutrition and/or dietary advice, previous studies have reported a relationship with GPs’ attitude toward other health care providers. Mathus-Vliegen et al. reported that because of some GPs’ negative attitude to dietitians, they often do not refer patients with obesity to these health care providers [24]. Moreover, problems with interdisciplinary communication impede GPs from referring overweight and obese patients [17, 24, 25]. Costs involved with dietary treatment were cited as a further inhibiting factor in referring patients to other health care providers for nutrition and/or dietary advice [26].

Clearly, the increasing prevalence and the seriousness of overweight and obesity highlight the necessity for solutions. Because of their central role in primary care, GPs are regarded as the principal health care providers in the management of overweight and obesity. Although guidelines for weight management are contained in the NHG Obesity Standard, there is a lack of information about GPs’ weight management policy in daily practice. Multiple factors have been found to be associated with GPs’ weight management policy, however there may be other influencing factors related to the GP, which may be informative in improving weight related referral rates. New in this study is the combination of the survey of GPs’ current weight management policy and the analysis of the factors associated with this policy. The objective of the present study is to explore GPs’ policy on the management of overweight and obesity as well as factors associated with this policy.

This explorative study showed that most GPs (82.9%) considered weight management for overweight and obese patients as part of their responsibility for providing care. However, weight is less frequently discussed by younger GPs. Next, weight is less frequently discussed with patients without weight-related comorbidities or with moderately overweight patients compared to obese patients. Nearly half of the GPs reported to refer obese patients to a weight management professional, preferably a dietitian. In addition, GPs who had frequent contact with a dietitian and those who felt more responsible for educating patients with obesity about weight-related comorbidities were more likely to refer obese patients. Finally, overweight and obese GPs were less likely to refer obese patients. The results of this study may be used to improve consistency in GPs’ weight management policy, for example, by means of communication and education materials.

This paper identified three major findings. First, GPs’ weight management policy appeared to be less targeted on primary prevention, neither on the social-environmental factors of overweight and obesity. The result that GPs are less involved in the weight management of people with moderate weight problems is in accordance with a study of Smith et al. [29]. Nonetheless, discussing weight to create awareness at an early stage of weight gain is important as this is the first step in behavioral change [30]. Besides, it is plausible to assert that reaching a healthy weight is easier at an early stage of weight gain. In addition, discussing the influence of medication use, psychosocial problems and environmental factors on patient’s weight management should be encouraged, as these appeared to be talked about less frequently. The importance of these topics is frequently described in the literature. For example, overeating is a common coping mechanism in emotional distress [31]. The environmental availability of healthy or unhealthy food is related to individuals’ food choices [32].

A second major finding of this study is that GPs’ personal characteristics such as age, BMI and concerns appeared to be related to their reported weight management policy. Part of these findings may be explained by the reported negative attitudes towards obese patients among younger GPs [22]. Similar to the findings of Brotons et al.,[33] a relationship between GPs’ BMI and frequency of discussing weight was absent. Possibly, overweight and obese GPs do not believe in an effective treatment of obesity in general. However, this should be studied further. From a patient’s perspective, overweight or obese GPs negatively affect credibility, level of trust and intention to follow weight management advice [34]. Therefore, GPs need to be aware of how they can act as a positive health role model by having a healthy BMI themselves. Finally, GPs who believed that promotion of a healthy weight is an important part of GP care likewise discussed weight more often. This implies that, in order to increase GPs frequency of discussing weight, GPs’ consciousness of weight management as part of their care should be stimulated, recommended by others as well [35]. With respect to this study that investigated the relationship between GPs’ characteristics and their weight management policy, there is a lack of information about the relationship between patients’ characteristics (e.g. age, sex, social economic status) and GPs’ weight management.

A third important finding is that GPs weight management policy can be improved on several ways. Only half of GPs refer their obese patients to other health care providers for dietary treatment and weight is not always discussed, although guidelines recommend doing it. GPs reported several reasons for not talking about weight, with lack of time as the most important cause. This result was in keeping with the findings of other studies [17, 26] and comprehensible with the fact that Dutch GPs are paid per patient by the primary health care insurance cover, based on an average consultation time of 10 minutes [36]. However, by preventing weight-related diseases by means of optimal weight management, it is presumable that by referring to a weight management specialist, GPs could save time in the end.

Next, patients’ lacking motivation was reported as a reason for GPs to not discuss patients’ weight problem, neither refer the patient to a dietitian. But in fact, patients’ lacking motivation is one of the main factors of failing weight management [37]. Therefore, patients’ lacking motivation should be a signal to discuss patients’ weight problem, use motivational interviewing and eventually refer to a specialized caregiver [37].

In contrast to other studies [26], only one third of the respondents reported costs as an important reason for not referring to other health care providers. In the Netherlands, costs may be of little importance due to the system of reimbursement of dietary treatment from Dutch primary health insurance cover. To date, three hours of dietary treatment is included in the standard health insurance package of all Dutch citizens which is obligatory for all Dutch citizens.

Remarkably, the presence of a dietitian in the same medical building was no indication for significantly higher referral rates. Problems in interdisciplinary communication are frequently mentioned in the literature [17, 24, 25]. The present findings indicate that GPs and dietitians should, even when they work in the same building, actively support frequent interdisciplinary communication, for example by providing face-to-face information about their processes [38].

This study has several limitations that may affect interpretation of the results. First, the number of non responders was substantial. In future studies, the response rate might be improved when using incentives, however, for the present study there was no budget available. Since web-based questionnaires appeared to result in higher response-rates [39, 40], this is a recommendation for future studies as well. The second limitation is that the validity and reliability of the questionnaire, though developed carefully, is unclear. Final limitation is the potential information bias. Possibly respondents have provided socially acceptable answers to the questions which may have resulted in a overestimation of the number of GPs with a healthy BMI and the frequency of discussing weight issues with patients. Studies that surveyed patients’ experiences, reported that GPs only intervened in half of the cases with obesity [11, 12]. The contrast between GPs’ reporting and patients’ experiences implicates for future studies that referral percentages need to be confirmed by using data from patient records. Other recommendations for further research are to assess the weight loss of patients referred to a dietitian in comparison to the weight loss of patients without a referral to a dietitian or to another health care provider in weight management.

The key strength of this study is the survey of GPs’ perception of their overweight and obesity management policy. Besides examining GPs’ self-reported frequency of discussing weight as well as their percentages for obesity management, we investigated factors associated with GPs’ weight management policy. The representative population of GPs from all over the Netherlands strengthens the study’s reliability.

In conclusion, this study showed that GPs’ self-reported weight management policy is in accordance with the professional guideline. Nonetheless, in the context of prevention, discussing weight at an early stage of weight gain deserves more attention, especially for younger GPs. Education programs should emphasize the importance of discussing the influence of medication use, psychosocial problems and environmental factors on weight gain. To increase the referral percentage for obesity management, it is important for GPs and dietitians to strengthen interdisciplinary collaboration. Shared feelings of responsibility between GPs and specialists in dietary treatment could play a fundamental role in the struggle to beat overweight and obesity.