Before Christmas the BJGP warned of the dangers of addiction. As the new year begins, the Journal, nothing if not consistent, focuses on another peril that transcends seasonal indulgence, obesity; always a tricky topic of discussion, and one made much trickier by the fact that much of the world is still hungry and that millions of children die from malnutrition. In the bloated West, however, and increasingly elsewhere, as other cultures ape our excesses, obesity is part of the rising tide of morbidity and mortality due to the non-communicable diseases that threaten to swamp our healthcare systems. Just as the causes of obesity are extremely complex, with roots in culture, poverty, geography, affluence, media manipulation, and multinationals, so the spectrum of responses is wide, with advocates of medical interventions at one end and the enemies of societal and medical paternalism lined up against them at the other. Our first editorial by Yates and colleagues provides a superb overview of this critical area.
Three research papers in this issue of the BJGP provide food for thought on this subject. The first, by Banks and colleagues from Bristol, looks at the costs of turning unhealthy diets into healthier ones. The background, of course, is that there is a prevalent belief that healthy and nutritious food is inevitably more expensive than junk, for all sorts of reasons including the costs of travel to supermarkets, the limited range of goods available in corner stores, and the accessibility, if not value for money, of chip shops and burger outlets. The Bristol researchers asked the families of obese children to keep 3-day food diaries and the food information provided was then theoretically adjusted, according to recognised nutritional guidelines, to create healthier eating patterns. Various food items were then priced at different levels reflecting different retail sources of food, such as a cheap supermarket and a local high street shop. Although the cheapest option was to buy low nutritional value food from a budget supermarket, the additional cost of a healthier diet from the same source was less than £2.50 per week, the difference between healthy and less healthy ingredients from a mid-range supermarket was negligible, and the costs of nutritious foods purchased in the high street could be less than buying junk food. These results need to be replicated in other studies and, if supported, find their way as a matter of urgency into schools, the media, and social policy.
The same group has also looked at the transferability of a tested hospital clinic model to help manage childhood obesity to a primary care setting, with encouraging results in terms of adherence to the interventions and BMI reduction, although the authors acknowledge that better patient selection and more effective interventions are still needed.
One of the simplest interventions of all, talking to patients, is one that we need to get better at. It has always seemed that GPs, and probably hospital doctors, are reasonably comfortable with giving firm advice to smokers and heavy drinkers, and that they are conspicuously uncomfortable and ineffective in engaging with obese patients, recognising that the conversation needs to negotiate all manner of interpersonal difficulties and is a political correctness minefield. Phillips and colleagues from Cardiff have looked at this problem in a study comparing GPs’ responses to simulated consultations for smoking cessation and for healthy eating advice, and their findings confirm these pre-suppositions. They conclude that clinicians lack confidence or have low perceptions of their ability to elicit change with dietary advice, and, quite rightly, that this has substantial training implications. It has huge implications for undergraduate teaching too, the ability to identify and approach factors in patients’ lives that may cause or worsen their illnesses, without discomfort or prejudice, is a core competency for generalists and specialists, and cannot be fobbed off by vague referrals to ‘the dietitian’ or the practice nurse.
Please find time to delve into The Review this month, and let us transport you to KwaZulu-Natal, Lebanon, Norway, Stalin’s Russia, and the storm-battered coasts of north-east Scotland, where you will read about treating tuberculosis and HIV, delivering health care in a conflict zone, tackling alcoholism with peer-support, a great play at the National Theatre, and the need to embrace and train for clinical leadership in the health service. A healthy diet, I hope.
- © British Journal of General Practice 2012
