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‘Water dripping on a stone’: a feasibility study of a healthy weight management conversation approach in routine general practice consultations

‘Water dripping on a stone’: a feasibility study of a healthy weight management conversation... Abstract Background Primary health care has an important role to play in the management of weight and yet discussions of healthy weight management do not occur optimally, indicating a need for simple tools and training in brief weight counselling. The ‘FABS’ approach (focusing on four topic areas: Food, Activity, Behaviour and Support) was developed to address this. Objectives To explore the feasibility of the ‘FABS’ approach within routine general practice consultations and its effectiveness in facilitating healthy weight conversations. Method The FABS approach was run for a trial period in five New Zealand general practices. The approach entailed staff training, the addition to the practice patient management system of a template outlining potential topics for discussion and a patient handout. GPs were asked to use the approach with any adult patient with a body mass index of over 28 kg/m2. A descriptive analysis of anonymized quantitative practice data was conducted, with limited qualitative data from an online clinician questionnaire and interviews with GPs and patients. Results Over 4 months, the template was opened 862 times by 27 clinicians in 830 patient consultations. All FABS topics were raised at least once. Physical activity was raised most frequently, followed by two food-related topics. There was variation between practices and between GPs. GPs tended to raise more topics within a single consultation than the training recommended. The limited clinician survey results and patient interviews also indicated positive responses to the approach. Conclusions It is possible to provide an infrastructure for healthy weight conversation approaches within general practice so that patients receive supportive and consistent messages on a regular basis. General practice is an appropriate setting for this due to the ongoing relationships with patients and team-based approach, but there is a need for effective training and education to ensure appropriate and effectively delivery. Continuity of care, lifestyle modification/health behaviour change, nutrition/diet, obesity management, physical activity/exercise, primary care Key Messages General practice is an appropriate setting for healthy weight talk. Infrastructure to support healthy weight talk in general practice is feasible. Such infrastructure can support regular and consistent messages. Patients and clinicians responded positively to a coordinated approach. Training and education for clinicians in discussing healthy weight is needed. Background Overweight and obesity are global health concerns with the highest rates found in Pacific Island nations, the USA, Middle Eastern countries and Aotearoa New Zealand (NZ) (1,2). NZ has the third highest levels of adult obesity in Organisation for Economic Co-operation and Development countries (3) and was ranked 44th in global trends for adult obesity in 2016 (4). The adult obesity rate in NZ was around one in three (30.9%) in 2018/19. The rates are higher for people identifying as Māori (the indigenous population; 48.2%), Pacific Islanders (living or born in NZ; 66.5%) and those living in more deprived areas (5), for a variety of complex reasons (6–8). There is a need to develop effective strategies to support people living with overweight and obesity, given their close association with a range of chronic health conditions and increased risks of developing metabolic diseases (2). Primary health care has an important role to play in managing chronic conditions, as the most frequent point of contact with the health system for most patients (9–11). These ongoing relationships facilitate the emotional support needed in this area. Talking with GPs and nurses may also be perceived as less stigmatizing than with specialist providers (12). However, there is a mismatch between the perceived importance of this and current practice (13). Discussions of healthy weight management in primary health care do not occur as frequently as desirable (14–16). Despite patient interest in input from primary care (17), only 25% of patients in Scotland (18) and 10–42% of Australian patients with overweight or obesity (19) report discussing weight with their GP. There are clearly opportunities for greater and more effective engagement in the area of weight management. Clinicians report a need for simple tools and training in brief weight counselling (14,20–22), allowing them to provide appropriate support to patients with overweight or obesity in a non-stigmatizing manner (23). Referring patients to external intensive weight management programmes has been the focus of other research in this area (24,25), but brief interventions for weight loss in primary care have also been shown to be effective (26). Use of such interventions is analogous to similar strategies for alcohol, mental health and low back pain (27–30), where regular, brief conversations have been successful, either within the standard consultation or with slightly longer consultation formats. A brief opportunistic intervention for use in NZ primary care was developed on the basis of previous research involving GPs, nurses and patients (31,32) and tested in several general practices establishing acceptability to both clinicians and patients (33). For the current study, this ultra brief approach was refined and updated in line with the NZ Ministry of Health clinical guidelines for weight management (34) with the specific aim of facilitating frequent, positive conversations between clinicians and patients about healthy weight. This approach (FABS: Food, Activity, Behaviour, Support) was trialled in five general practices in the lower North Island of New Zealand by a Primary Health Organization (PHO). The aim of this study was to investigate the feasibility of using this brief opportunistic approach with adult patients in routine general practice consultations during the pilot period, as well as its effectiveness in facilitating healthy weight conversations. Methods This study used a sample of anonymized quantitative practice data about a healthy weight conversation approach collected over a 4-month period in 2018. Setting Five general practices with a record of routinely tracking weight and height for a minimum of 50% of enrolled adult populations over the previous 5 years were purposefully recruited within one region of NZ. Practices were selected to reflect different geographical locations, populations and practice sizes within the greater Wellington region. Participants All 36 clinicians in the general practices were invited to participate in the training session and to use the approach. They were trained to use the intervention opportunistically within routine consultations with any adult patient with a body mass index of over 28 kg/m2, identified either from their records or from calculation within the consultation. Description of the approach The key content was developed from previous work and adapted to four topic areas: Food, Activity, Behaviour and Support which gave the name ‘FABS’. The FABS approach has a whole-practice focus to achieve a ‘water dripping on a stone’ effect through repeated small consistent and supportive messages with any clinician a patient sees, as and when appropriate, as a part of routine consultations. There are three elements to the approach: staff training, a screening template and a tear-off pad for use as a prompt for the clinician and/or as a patient handout. Training sessions of 45–120 minutes were conducted onsite with individual practices and were delivered by a multidisciplinary team: a GP, an interactional sociolinguist and a public health specialist (all part of the research team). All staff were encouraged to attend the training sessions, including GPs, primary care nurses, practice managers and administrative staff. The training included current thinking around weight management, conversational strategies for raising the topic of weight management in routine consultations and advice on appropriate non-stigmatizing language and approaches. Key conversational strategies developed from our previous research were to introduce the topic with delicacy, not to pursue the topic in the face of opposition or lack of interest by the patient (31), and the importance of eliciting patient perspectives on weight management (35). The tear-off pad covered the four ‘FABS’ topic areas, each with three to five bullet point prompts. These were not intended to be delivered all at once; training encouraged a focus on one or two points relevant to the patient in a single consultation, with points to be revisited or added to as opportunities arose and as appropriate. The screening template was integrated with the Patient Management System (PMS) computer dashboard. This enabled clinicians to record the conversations in a structured way on the patient record, ticking which topics had been discussed. The outcome section enabled patients to be classified as ‘pre-contemplative’ (not open to discussion at that point), ‘contemplative’ (thinking about the topic) or ‘action’ (key messages were given and positively received by the patient), based on the transtheoretical model of change (36). The template could be opened and added to multiple times by any clinician, recording multiple discussions of topics. The overall use of the template for an individual patient could be monitored by the practice or clinicians with a chart function which tracked engagement over time, as well as interactions with multiple clinicians. The intervention was used over a 4-month period, with a small financial incentive from the PHO for practices to take part and participate in the training, data input and feedback. Data collection and analysis The feasibility and effectiveness of the approach in terms of facilitating conversation was measured through number of clinicians using the template, number of consultations it was used with and number of topics raised, with supplementary qualitative feedback via a survey and interviews with six participants. Our focus was on how effective the approach was in supporting healthy weight conversations and did not measure behaviour or weight change. Anonymized practice data were captured via entries into the FABS template by clinicians in business as usual conditions. Patients were not directly recruited to participate as the analysis used anonymized routine data. The capture of data through the PMS meant all entries were collated under the name of the patient’s GP without indicating use of the template by other clinicians (usually nurses). All clinicians in the practices were invited to respond to a simple online clinician survey, whether or not they had used the FABS approach and screening tool. The interviews were conducted with two GPs and four patients as part of a small-scale separate related study (37), in which GPs using the intervention and their patients were asked to consent to video recording of their consultation. Participants in each recorded consultation were interviewed soon after the recording about how the consultation went and the topic of weight. GPs were also asked general questions about barriers and enablers to using the intervention and their reaction to the FABS approach. Interviews with patients included questions on their reaction to how the topic of healthy weight was raised with them. Descriptive analysis was conducted of the demographic characteristics of the patients with whom the template was used, as well as the use of the template. A framework analysis of interview responses was conducted. Results Practice demographics The practices ranged in size between 4000 and 11,000 enrolled patients. Three were suburban, one was urban and one was rural with between 3 and 10 GPs in each practice. Clinician demographics Twenty-seven GPs in the five pilot practices (75%) used the intervention: 12 men and 15 women. FABS was used by all or almost all GPs in three of the practices and by half of the GPs in the other two practices, most of whom used it for the entire pilot period (See Supplementary Table 1 for more detail). Patient demographics The profile of the ‘FABS’ patients is similar to the overall enrolled population of each practice in terms of gender, ethnicity and socio-economic status, with the age profile differing as expected given the selection criteria (See Supplementary Table 2 for more detail). There was a gender imbalance towards men in one practice and towards women in another, despite the enrolled populations being balanced for gender. Despite clinicians being guided to use this approach with adult patients, the data show 7 clinicians used it with 10 patients under the age of 15 years. The demographic profile of the patients is shown in Table 1 (Demographic data was not always entered by the GP, resulting in some missing data). Table 1. Demographic characteristics of patients receiving a healthy weight intervention in five primary health care practices in New Zealand (2018) Practice . . 1 . 2 . 3 . 4 . 5 . Number of patient consults 830 162 45 105 53 465 N (%) % % % % % Gender  Male 387 (47) 51 52 62 33 43  Female 433 (52) 48 47 38 66 56  Not recorded 10 (1) 1 1 0 1 1 Ethnicity  Asian 71 (9) 6 2 15 8 9  European 634 (76) 83 80 57 70 79  Māori 48 (6) 7 16 11 7 3  Pacific 47 (6) 3 0 8 11 6  Other 18 (2) 1 0 10 2 1  Unknown/ not recorded 12 (1) 0 2 0 2 2 Age  0–14a 10 (1) 1 2 2 2 1  15–24 46 (6) 5 4 6 2 6  25–44 161 (19) 19 16 14 34 20  45–64 372 (45) 49 47 47 42 43  65+ 231 (28) 25 29 30 19 29  Not recorded 10 (1) 1 2 1 2 1 Quintileb  1 278 (33) 35 4 25 26 39  2 217 (26) 27 18 38 34 23  3 156 (19) 18 11 17 13 21  4 98 (12) 14 38 12 17 8  5 56 (3) 4 27 4 8 6  Not recorded 25 (3) 2 2 4 2 3 Practice . . 1 . 2 . 3 . 4 . 5 . Number of patient consults 830 162 45 105 53 465 N (%) % % % % % Gender  Male 387 (47) 51 52 62 33 43  Female 433 (52) 48 47 38 66 56  Not recorded 10 (1) 1 1 0 1 1 Ethnicity  Asian 71 (9) 6 2 15 8 9  European 634 (76) 83 80 57 70 79  Māori 48 (6) 7 16 11 7 3  Pacific 47 (6) 3 0 8 11 6  Other 18 (2) 1 0 10 2 1  Unknown/ not recorded 12 (1) 0 2 0 2 2 Age  0–14a 10 (1) 1 2 2 2 1  15–24 46 (6) 5 4 6 2 6  25–44 161 (19) 19 16 14 34 20  45–64 372 (45) 49 47 47 42 43  65+ 231 (28) 25 29 30 19 29  Not recorded 10 (1) 1 2 1 2 1 Quintileb  1 278 (33) 35 4 25 26 39  2 217 (26) 27 18 38 34 23  3 156 (19) 18 11 17 13 21  4 98 (12) 14 38 12 17 8  5 56 (3) 4 27 4 8 6  Not recorded 25 (3) 2 2 4 2 3 aThe intervention is targeted to adults but was used in a small number of consultations with children. bA measure of socio-economic deprivation in New Zealand: Quintile 1 represents people living in the least deprived 20% of census area units; Quintile 5 represents people living in the most deprived 20% of census area units. Open in new tab Table 1. Demographic characteristics of patients receiving a healthy weight intervention in five primary health care practices in New Zealand (2018) Practice . . 1 . 2 . 3 . 4 . 5 . Number of patient consults 830 162 45 105 53 465 N (%) % % % % % Gender  Male 387 (47) 51 52 62 33 43  Female 433 (52) 48 47 38 66 56  Not recorded 10 (1) 1 1 0 1 1 Ethnicity  Asian 71 (9) 6 2 15 8 9  European 634 (76) 83 80 57 70 79  Māori 48 (6) 7 16 11 7 3  Pacific 47 (6) 3 0 8 11 6  Other 18 (2) 1 0 10 2 1  Unknown/ not recorded 12 (1) 0 2 0 2 2 Age  0–14a 10 (1) 1 2 2 2 1  15–24 46 (6) 5 4 6 2 6  25–44 161 (19) 19 16 14 34 20  45–64 372 (45) 49 47 47 42 43  65+ 231 (28) 25 29 30 19 29  Not recorded 10 (1) 1 2 1 2 1 Quintileb  1 278 (33) 35 4 25 26 39  2 217 (26) 27 18 38 34 23  3 156 (19) 18 11 17 13 21  4 98 (12) 14 38 12 17 8  5 56 (3) 4 27 4 8 6  Not recorded 25 (3) 2 2 4 2 3 Practice . . 1 . 2 . 3 . 4 . 5 . Number of patient consults 830 162 45 105 53 465 N (%) % % % % % Gender  Male 387 (47) 51 52 62 33 43  Female 433 (52) 48 47 38 66 56  Not recorded 10 (1) 1 1 0 1 1 Ethnicity  Asian 71 (9) 6 2 15 8 9  European 634 (76) 83 80 57 70 79  Māori 48 (6) 7 16 11 7 3  Pacific 47 (6) 3 0 8 11 6  Other 18 (2) 1 0 10 2 1  Unknown/ not recorded 12 (1) 0 2 0 2 2 Age  0–14a 10 (1) 1 2 2 2 1  15–24 46 (6) 5 4 6 2 6  25–44 161 (19) 19 16 14 34 20  45–64 372 (45) 49 47 47 42 43  65+ 231 (28) 25 29 30 19 29  Not recorded 10 (1) 1 2 1 2 1 Quintileb  1 278 (33) 35 4 25 26 39  2 217 (26) 27 18 38 34 23  3 156 (19) 18 11 17 13 21  4 98 (12) 14 38 12 17 8  5 56 (3) 4 27 4 8 6  Not recorded 25 (3) 2 2 4 2 3 aThe intervention is targeted to adults but was used in a small number of consultations with children. bA measure of socio-economic deprivation in New Zealand: Quintile 1 represents people living in the least deprived 20% of census area units; Quintile 5 represents people living in the most deprived 20% of census area units. Open in new tab Clinician uptake The number of clinicians using the intervention (27 out of 36) shows a relatively high level of uptake. While most of these are likely to have been GPs, a number of nurses also used the approach (according to survey data). The intervention was used in 830 patient consultations with 757 patients. Seventy-six per cent of consultations were with patients of European background with smaller numbers of Asian, indigenous Māori and Pacific ethnicity, and 59% of higher socio-economic status (quintiles 1 and 2). The template was opened a total of 862 times over the 4-month period. This equates to approximately twice per day per practice. It was used consistently throughout the time. Topic coverage All topics in the FABS intervention were raised during the 4 months, however, some were raised much more frequently than others. The ranked distribution of topics selected is shown in Table 2. Table 2. Ranking of healthy weight topics ticked on a screening tool in five primary health care practices in New Zealand (2018) Topic . Explanation . Number of times raised . % of total . ACTIVITY - Physical Add short, physical activities into your daily routine great for wellbeing, heart health and mood 581 23 FOOD - Fat, Salt, Sugar Go for unsaturated fats, low salt, little or no sugar. 417 17 FOOD - Portion Size Reduce portion sizes, use a smaller plate for food and limit snacking. 381 15 ACTIVITY - Move Move more, sit less, sleep well. 364 15 FOOD - Drinks Drink more water, less alcohol and fewer sugary drinks 215 9 FOOD - Variety Add variety – different colours and types, more plant-based foods. 206 8 ACTIVITY - Sleep Aim for a regular sleep routine, 7 – 8 hours is generally recommended. 151 6 SUPPORT - Self-care Be kind to yourself – what makes you feel happy and relaxed? 134 5 SUPPORT - Stress Reflect on any stress in your life and how it affects your eating, drinking and sleep patterns 102 4 BEHAVIOUR - Red Flags? Identify your red flags – food and exercise challenges, stress 68 3 SUPPORT - Support Family, whanau, friends’ support is great for our overall wellbeing, harness these for a healthy weight. 55 2 BEHAVIOUR - One Step Take one step at a time, small changes to healthier food, drink, sleep and activity can give you lasting benefits. 34 1 BEHAVIOUR - Green Flags? Identify your green flags – things you can change to support a healthy weight. 32 1 ACTIVITY - Green Rx Is a green prescription suitable for you? 28 1 Topic . Explanation . Number of times raised . % of total . ACTIVITY - Physical Add short, physical activities into your daily routine great for wellbeing, heart health and mood 581 23 FOOD - Fat, Salt, Sugar Go for unsaturated fats, low salt, little or no sugar. 417 17 FOOD - Portion Size Reduce portion sizes, use a smaller plate for food and limit snacking. 381 15 ACTIVITY - Move Move more, sit less, sleep well. 364 15 FOOD - Drinks Drink more water, less alcohol and fewer sugary drinks 215 9 FOOD - Variety Add variety – different colours and types, more plant-based foods. 206 8 ACTIVITY - Sleep Aim for a regular sleep routine, 7 – 8 hours is generally recommended. 151 6 SUPPORT - Self-care Be kind to yourself – what makes you feel happy and relaxed? 134 5 SUPPORT - Stress Reflect on any stress in your life and how it affects your eating, drinking and sleep patterns 102 4 BEHAVIOUR - Red Flags? Identify your red flags – food and exercise challenges, stress 68 3 SUPPORT - Support Family, whanau, friends’ support is great for our overall wellbeing, harness these for a healthy weight. 55 2 BEHAVIOUR - One Step Take one step at a time, small changes to healthier food, drink, sleep and activity can give you lasting benefits. 34 1 BEHAVIOUR - Green Flags? Identify your green flags – things you can change to support a healthy weight. 32 1 ACTIVITY - Green Rx Is a green prescription suitable for you? 28 1 Open in new tab Table 2. Ranking of healthy weight topics ticked on a screening tool in five primary health care practices in New Zealand (2018) Topic . Explanation . Number of times raised . % of total . ACTIVITY - Physical Add short, physical activities into your daily routine great for wellbeing, heart health and mood 581 23 FOOD - Fat, Salt, Sugar Go for unsaturated fats, low salt, little or no sugar. 417 17 FOOD - Portion Size Reduce portion sizes, use a smaller plate for food and limit snacking. 381 15 ACTIVITY - Move Move more, sit less, sleep well. 364 15 FOOD - Drinks Drink more water, less alcohol and fewer sugary drinks 215 9 FOOD - Variety Add variety – different colours and types, more plant-based foods. 206 8 ACTIVITY - Sleep Aim for a regular sleep routine, 7 – 8 hours is generally recommended. 151 6 SUPPORT - Self-care Be kind to yourself – what makes you feel happy and relaxed? 134 5 SUPPORT - Stress Reflect on any stress in your life and how it affects your eating, drinking and sleep patterns 102 4 BEHAVIOUR - Red Flags? Identify your red flags – food and exercise challenges, stress 68 3 SUPPORT - Support Family, whanau, friends’ support is great for our overall wellbeing, harness these for a healthy weight. 55 2 BEHAVIOUR - One Step Take one step at a time, small changes to healthier food, drink, sleep and activity can give you lasting benefits. 34 1 BEHAVIOUR - Green Flags? Identify your green flags – things you can change to support a healthy weight. 32 1 ACTIVITY - Green Rx Is a green prescription suitable for you? 28 1 Topic . Explanation . Number of times raised . % of total . ACTIVITY - Physical Add short, physical activities into your daily routine great for wellbeing, heart health and mood 581 23 FOOD - Fat, Salt, Sugar Go for unsaturated fats, low salt, little or no sugar. 417 17 FOOD - Portion Size Reduce portion sizes, use a smaller plate for food and limit snacking. 381 15 ACTIVITY - Move Move more, sit less, sleep well. 364 15 FOOD - Drinks Drink more water, less alcohol and fewer sugary drinks 215 9 FOOD - Variety Add variety – different colours and types, more plant-based foods. 206 8 ACTIVITY - Sleep Aim for a regular sleep routine, 7 – 8 hours is generally recommended. 151 6 SUPPORT - Self-care Be kind to yourself – what makes you feel happy and relaxed? 134 5 SUPPORT - Stress Reflect on any stress in your life and how it affects your eating, drinking and sleep patterns 102 4 BEHAVIOUR - Red Flags? Identify your red flags – food and exercise challenges, stress 68 3 SUPPORT - Support Family, whanau, friends’ support is great for our overall wellbeing, harness these for a healthy weight. 55 2 BEHAVIOUR - One Step Take one step at a time, small changes to healthier food, drink, sleep and activity can give you lasting benefits. 34 1 BEHAVIOUR - Green Flags? Identify your green flags – things you can change to support a healthy weight. 32 1 ACTIVITY - Green Rx Is a green prescription suitable for you? 28 1 Open in new tab The top ranked topic was physical activity, followed by two food-related topics. Portion size was ranked third in frequency, although it was the most frequently mentioned topic in two practices (1 and 4). Overall, however, activity-related messages made up two of the top three messages in all practices (See Supplementary Figure S1 for detail.). There was also considerable variation between clinicians within practices as to which topics were raised most often, as shown in Figure 1, which shows the distribution of topics for three clinicians. Figure 1. Open in new tabDownload slide Healthy weight (FABS) topics raised by three individual primary care clinicians in New Zealand (2018). Figure 1. Open in new tabDownload slide Healthy weight (FABS) topics raised by three individual primary care clinicians in New Zealand (2018). Number of topics raised per consultation Despite the advice in training sessions to cover only 1 or 2 topics per consultation, there was wide variety between practices and within practices in this regard, ranging from 1 to 14 topics raised in a single consultation. Clinicians in two practices (1 and 5) followed the advice to raise only one to two topics per consultation most closely, but others tended to discuss a larger number of topics than suggested. Again, there was also variation between clinicians within a practice. Multiple use with individual patients Sixty-three patients received the intervention more than once, although most of these were seen by a single GP in Practice 5 (76%; n = 48). Most of this group (n = 56) received the intervention twice, with seven receiving it over three or four visits, mostly spaced 2–3 months apart. Table 3 shows which topics were repeated or added in subsequent consultations. Physical activity was the topic most often repeated and was also more likely to be repeated than added. Sleep was a topic that was more likely to be added in later. Table 3. Number of healthy weight topics repeated or added in a later consult in five primary health care practices in New Zealand (2018) Topics . Added . Repeated . FOOD - Portion Size 7 9 FOOD - Variety 2 2 FOOD - Drinks 9 2 FOOD - Fat, Salt, Sugar 14 14 ACTIVITY - Move 13 6 ACTIVITY - Physical 11 30 ACTIVITY - Sleep 12 2 ACTIVITY - Green Rx 0 0 BEHAVIOUR - One Step 0 0 BEHAVIOUR - Green Flags? 3 0 BEHAVIOUR - Red Flags? 2 2 SUPPORT - Self-care 4 2 SUPPORT - Stress 6 1 SUPPORT - Support 2 2 Total 85 72 Topics . Added . Repeated . FOOD - Portion Size 7 9 FOOD - Variety 2 2 FOOD - Drinks 9 2 FOOD - Fat, Salt, Sugar 14 14 ACTIVITY - Move 13 6 ACTIVITY - Physical 11 30 ACTIVITY - Sleep 12 2 ACTIVITY - Green Rx 0 0 BEHAVIOUR - One Step 0 0 BEHAVIOUR - Green Flags? 3 0 BEHAVIOUR - Red Flags? 2 2 SUPPORT - Self-care 4 2 SUPPORT - Stress 6 1 SUPPORT - Support 2 2 Total 85 72 Open in new tab Table 3. Number of healthy weight topics repeated or added in a later consult in five primary health care practices in New Zealand (2018) Topics . Added . Repeated . FOOD - Portion Size 7 9 FOOD - Variety 2 2 FOOD - Drinks 9 2 FOOD - Fat, Salt, Sugar 14 14 ACTIVITY - Move 13 6 ACTIVITY - Physical 11 30 ACTIVITY - Sleep 12 2 ACTIVITY - Green Rx 0 0 BEHAVIOUR - One Step 0 0 BEHAVIOUR - Green Flags? 3 0 BEHAVIOUR - Red Flags? 2 2 SUPPORT - Self-care 4 2 SUPPORT - Stress 6 1 SUPPORT - Support 2 2 Total 85 72 Topics . Added . Repeated . FOOD - Portion Size 7 9 FOOD - Variety 2 2 FOOD - Drinks 9 2 FOOD - Fat, Salt, Sugar 14 14 ACTIVITY - Move 13 6 ACTIVITY - Physical 11 30 ACTIVITY - Sleep 12 2 ACTIVITY - Green Rx 0 0 BEHAVIOUR - One Step 0 0 BEHAVIOUR - Green Flags? 3 0 BEHAVIOUR - Red Flags? 2 2 SUPPORT - Self-care 4 2 SUPPORT - Stress 6 1 SUPPORT - Support 2 2 Total 85 72 Open in new tab Clinician and patient feedback Survey data Eight clinicians (GPs and nurses) from three of the five practices completed the online survey, seven of whom had attended the training session and had used the FABS approach for 2 months or more on a regular basis. All rated the approach ‘very easy’ or ‘relatively easy’ to use. Six of the eight rated it ‘neutral’ to ‘easy’ in terms of incorporating the approach into consultations and raising the topic. Five intended to continue using the intervention in some form. Most clinicians (seven out of eight) reported raising the topic of weight more frequently with FABS and felt that it was easier to record what had been discussed (six out of eight). There was variation in suggestions for wider rollout: improving the screening template (n = 3), further training (n = 2) and developing App versions of the handout (n = 2). The main reasons given by those clinicians who did not use the screening template were forgetting to use it and the time pressure of 15-minute appointments. Interview data Supplementary data were obtained from interviews with two GPs and four patients who consented to their consultations being video recorded and to a brief interview for a related study. Illustrative quotes are shown in Table 4. Table 4. Illustrative quotes from six participant interviews within five primary health care practices in New Zealand (2018) Quotes from clinician interviews . Quote 1: I think it’s been particularly useful in that we talk about diet and exercise all the time, but I don’t think I ever talk to a patient about that lack of sleep can have on your weight. …until there was a little tool in front of me, I went oh! ... that was the first time I had ever connected those two things. (GP07) Quote 2: All these guys I’ve kind of known before, you know. (GP37) Quote 3: So ((NAME-PT))’s been a patient of mine for a number of years now, so I know ((NAME-PT)) very well. (GP07) Quote 4: They haven’t come about their weight, generally speaking and it’s my agenda that I want to talk to them about their weight. And I want to do that within 15 minutes. That’s the problem. It’s not the tool, it’s the time. (GP07) Quote 5: it wouldn’t be the right thing to do. Her weight is like her least of her problems (GP37) Quote 6: I think that she would take a lot of consultations. You have to reiterate this… for it to make a difference…. It’s something that is an ongoing process too… she’s got a long way to go. (GP37) Quotes from patient interviews . Quote 7: I am really quite happy to talk to my GP about anything at all… it was appropriate today, because we’d been talking about my knees....and about the problems the excess weight can cause... so it was an appropriate time for her to bring it up. (GP07-08) Quote 8: RS:And how did you feel about those extra topics being raised? PT:Oh … I like ... to cover those things. Even if I’ve been over them before. (GP07-09) Quote 9: RS:So were you comfortable with him raising the topic with you? PT:Yes, yes. Yeah. Yeah. Definitely. (GP37-01) Quotes from clinician interviews . Quote 1: I think it’s been particularly useful in that we talk about diet and exercise all the time, but I don’t think I ever talk to a patient about that lack of sleep can have on your weight. …until there was a little tool in front of me, I went oh! ... that was the first time I had ever connected those two things. (GP07) Quote 2: All these guys I’ve kind of known before, you know. (GP37) Quote 3: So ((NAME-PT))’s been a patient of mine for a number of years now, so I know ((NAME-PT)) very well. (GP07) Quote 4: They haven’t come about their weight, generally speaking and it’s my agenda that I want to talk to them about their weight. And I want to do that within 15 minutes. That’s the problem. It’s not the tool, it’s the time. (GP07) Quote 5: it wouldn’t be the right thing to do. Her weight is like her least of her problems (GP37) Quote 6: I think that she would take a lot of consultations. You have to reiterate this… for it to make a difference…. It’s something that is an ongoing process too… she’s got a long way to go. (GP37) Quotes from patient interviews . Quote 7: I am really quite happy to talk to my GP about anything at all… it was appropriate today, because we’d been talking about my knees....and about the problems the excess weight can cause... so it was an appropriate time for her to bring it up. (GP07-08) Quote 8: RS:And how did you feel about those extra topics being raised? PT:Oh … I like ... to cover those things. Even if I’ve been over them before. (GP07-09) Quote 9: RS:So were you comfortable with him raising the topic with you? PT:Yes, yes. Yeah. Yeah. Definitely. (GP37-01) Open in new tab Table 4. Illustrative quotes from six participant interviews within five primary health care practices in New Zealand (2018) Quotes from clinician interviews . Quote 1: I think it’s been particularly useful in that we talk about diet and exercise all the time, but I don’t think I ever talk to a patient about that lack of sleep can have on your weight. …until there was a little tool in front of me, I went oh! ... that was the first time I had ever connected those two things. (GP07) Quote 2: All these guys I’ve kind of known before, you know. (GP37) Quote 3: So ((NAME-PT))’s been a patient of mine for a number of years now, so I know ((NAME-PT)) very well. (GP07) Quote 4: They haven’t come about their weight, generally speaking and it’s my agenda that I want to talk to them about their weight. And I want to do that within 15 minutes. That’s the problem. It’s not the tool, it’s the time. (GP07) Quote 5: it wouldn’t be the right thing to do. Her weight is like her least of her problems (GP37) Quote 6: I think that she would take a lot of consultations. You have to reiterate this… for it to make a difference…. It’s something that is an ongoing process too… she’s got a long way to go. (GP37) Quotes from patient interviews . Quote 7: I am really quite happy to talk to my GP about anything at all… it was appropriate today, because we’d been talking about my knees....and about the problems the excess weight can cause... so it was an appropriate time for her to bring it up. (GP07-08) Quote 8: RS:And how did you feel about those extra topics being raised? PT:Oh … I like ... to cover those things. Even if I’ve been over them before. (GP07-09) Quote 9: RS:So were you comfortable with him raising the topic with you? PT:Yes, yes. Yeah. Yeah. Definitely. (GP37-01) Quotes from clinician interviews . Quote 1: I think it’s been particularly useful in that we talk about diet and exercise all the time, but I don’t think I ever talk to a patient about that lack of sleep can have on your weight. …until there was a little tool in front of me, I went oh! ... that was the first time I had ever connected those two things. (GP07) Quote 2: All these guys I’ve kind of known before, you know. (GP37) Quote 3: So ((NAME-PT))’s been a patient of mine for a number of years now, so I know ((NAME-PT)) very well. (GP07) Quote 4: They haven’t come about their weight, generally speaking and it’s my agenda that I want to talk to them about their weight. And I want to do that within 15 minutes. That’s the problem. It’s not the tool, it’s the time. (GP07) Quote 5: it wouldn’t be the right thing to do. Her weight is like her least of her problems (GP37) Quote 6: I think that she would take a lot of consultations. You have to reiterate this… for it to make a difference…. It’s something that is an ongoing process too… she’s got a long way to go. (GP37) Quotes from patient interviews . Quote 7: I am really quite happy to talk to my GP about anything at all… it was appropriate today, because we’d been talking about my knees....and about the problems the excess weight can cause... so it was an appropriate time for her to bring it up. (GP07-08) Quote 8: RS:And how did you feel about those extra topics being raised? PT:Oh … I like ... to cover those things. Even if I’ve been over them before. (GP07-09) Quote 9: RS:So were you comfortable with him raising the topic with you? PT:Yes, yes. Yeah. Yeah. Definitely. (GP37-01) Open in new tab One GP particularly commented on the usefulness of the FABS approach as a prompt to discuss less commonly raised issues connected to weight, such as sleep (Quote 1). The main enabler mentioned by both GPs for feeling comfortable raising the topic was the context of knowing the patient well from a long relationship (Quotes 2 and 3). Three main challenges to the approach were noted: time limitations (Quote 4), sensitivity to the patient agenda (Quote 4) and the appropriateness of raising the topic in the context of other patient issues (Quote 5). One GP commented on one key aspect of the FABS approach, the need for repeated conversations over time (Quote 6). The patients interviewed all gave positive feedback about how the topic of weight was raised with them in their consultation (Quotes 7–9), with one mentioning the link to their own agenda as being important (Quote 7). Conclusions This study demonstrated that brief discussion of healthy weight can be incorporated into routine primary health care consultations in different practice settings and by different clinicians. This can be achieved without significant impact on the length or other business of the consultation itself or on the clinician–patient relationship. Clinicians and patients both responded positively to the approach. While conducted within a local New Zealand setting, we feel there are sufficient commonalities in primary care practice in many other Organisation for Economic Co-operation and Development countries for the findings to have international relevance. A key benefit of the FABS approach is that it is a very brief intervention which is able to be used within routine consultations. This distinguishes it from other primary care obesity approaches that refer to weight loss programmes (24,25,38), or provide much more intensive focused interventions (38,39). Brief approaches have been found effective in various areas of primary health care (28–30), although few of those found in the obesity literature can be described as truly brief. The approach used was acceptable to both men and women. While this is important for global trends and predictions of more women than men living with obesity by 2025 (22), acceptability to men is also important since in some countries including NZ more men than women live with obesity (21). The variation between practices and among clinicians (of both frequency of topics raised and number of topics raised per consultation) demonstrates the flexibility of the approach in terms of tailoring to local issues or concerns. Interestingly, the raising of multiple topics in single consultations is at odds with reported lack of time in consultations (and was also contrary to the training recommendations). The top ranking of topics relating to physical activity is consistent with earlier research indicating that clinicians are more comfortable raising this topic or believe this is the main cause of obesity (40), notwithstanding its relevance for some patients. When food-related messages were delivered, the high ranking of the fat/sugar/salt topic compared to portion size may reflect the fact that sugar currently has a high profile in the media (41). The approach was used with some patients over multiple consultations even within the short timeframe of 4 months. The focus on clinicians having short conversations raising only one or two points in any one consultation facilitates this, reinforcing messages or adding less frequently mentioned topics, such as sleep, that might otherwise get missed. The tear-off A5 pad used by clinicians and given to patients was a low-cost resource that was positively received. Further work would be required to establish if this was the most appropriate resource or whether other mediums (such as apps) should also be developed (as well or instead). While there were some reported challenges with the use of FABS (time constraints, patient agendas and competing issues), the approach was found to be feasible within general practice where established patient relationships appear to be important, in keeping with other research (33,40). If the FABS approach is to be used more widely, the content and delivery of the health professional training would need to be refined and tailored to local conditions, particularly to specific ethnic groups who are disproportionately affected by weight issues, preferably through co-design processes. Scalable modes of training delivery such as web-based self-access resources combined with face-to-face training would also be required. The strengths of this study were that it was conducted within routine consultations in a range of GP practices and with a very brief intervention. While intended for use with adult patients, we have reported the limited use made of it with younger patients by some clinicians to illustrate the pragmatic nature of introducing innovations into primary care settings. Limitations include the small-scale study, and the fact that the number of topics discussed was self reported (i.e. clinician use of the screening tool rather than direct evidence such as video recording). Another limitation arose from a technical constraint of the screening template which was linked to the patient’s GP and thus did not distinguish use by individual clinicians, making it impossible to break the data down by type of clinician. The patients involved in this study were not drawn from a representative sample of the NZ population and as a descriptive study, no statistical analyses were conducted. The supplementary qualitative data are based on a very small number of interviews. This study has demonstrated that it is possible to provide an infrastructure for healthy weight management within general practice so that patients receive supportive, non-stigmatizing and consistent messages around healthy behaviours on a regular basis, ‘like water dripping on a stone’. General practice is an appropriate site for this kind of intervention due to the ongoing relationships with patients, but there is a need for effective training and education to ensure the approach is delivered appropriately and effectively. Declaration Funding: This study was funded by Tū Ora Compass Health as part of a Ministry of Health project. Tū Ora Compass Health was responsible for the collection of practice data. The supplementary data are from a study funded by a University of Otago Research Grant (2018). Ethical approval: The study was approved by the University of Otago Human Ethics Committee (Health) (HD18/033 and HE18/005). Conflict of interest: SD is an employee of Tū Ora Compass Health, which might have an interest in the submitted work. Acknowledgements The authors gratefully acknowledge the primary care general practices that participated in the pilot intervention, in particular the clinicians and patients in whose consultations the intervention was delivered. The authors also thank Tū Ora Compass Health for their assistance, in particular Dipan Ranchhod (Senior Analyst) and Bronwen Warren (General Manager Clinical Services). References 1. NCD Risk Factor Collaboration . Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19· 2 million participants . Lancet 2016 ; 387 ( 10026 ): 1377 – 96 . Crossref Search ADS PubMed WorldCat 2. World Health Organization , Global Health Observatory. Prevalence of Obesity Amongst Adults, Aged 16+, 1975–2016, Both Sexes . 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‘Water dripping on a stone’: a feasibility study of a healthy weight management conversation approach in routine general practice consultations

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Oxford University Press
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0263-2136
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1460-2229
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10.1093/fampra/cmaa122
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Abstract

Abstract Background Primary health care has an important role to play in the management of weight and yet discussions of healthy weight management do not occur optimally, indicating a need for simple tools and training in brief weight counselling. The ‘FABS’ approach (focusing on four topic areas: Food, Activity, Behaviour and Support) was developed to address this. Objectives To explore the feasibility of the ‘FABS’ approach within routine general practice consultations and its effectiveness in facilitating healthy weight conversations. Method The FABS approach was run for a trial period in five New Zealand general practices. The approach entailed staff training, the addition to the practice patient management system of a template outlining potential topics for discussion and a patient handout. GPs were asked to use the approach with any adult patient with a body mass index of over 28 kg/m2. A descriptive analysis of anonymized quantitative practice data was conducted, with limited qualitative data from an online clinician questionnaire and interviews with GPs and patients. Results Over 4 months, the template was opened 862 times by 27 clinicians in 830 patient consultations. All FABS topics were raised at least once. Physical activity was raised most frequently, followed by two food-related topics. There was variation between practices and between GPs. GPs tended to raise more topics within a single consultation than the training recommended. The limited clinician survey results and patient interviews also indicated positive responses to the approach. Conclusions It is possible to provide an infrastructure for healthy weight conversation approaches within general practice so that patients receive supportive and consistent messages on a regular basis. General practice is an appropriate setting for this due to the ongoing relationships with patients and team-based approach, but there is a need for effective training and education to ensure appropriate and effectively delivery. Continuity of care, lifestyle modification/health behaviour change, nutrition/diet, obesity management, physical activity/exercise, primary care Key Messages General practice is an appropriate setting for healthy weight talk. Infrastructure to support healthy weight talk in general practice is feasible. Such infrastructure can support regular and consistent messages. Patients and clinicians responded positively to a coordinated approach. Training and education for clinicians in discussing healthy weight is needed. Background Overweight and obesity are global health concerns with the highest rates found in Pacific Island nations, the USA, Middle Eastern countries and Aotearoa New Zealand (NZ) (1,2). NZ has the third highest levels of adult obesity in Organisation for Economic Co-operation and Development countries (3) and was ranked 44th in global trends for adult obesity in 2016 (4). The adult obesity rate in NZ was around one in three (30.9%) in 2018/19. The rates are higher for people identifying as Māori (the indigenous population; 48.2%), Pacific Islanders (living or born in NZ; 66.5%) and those living in more deprived areas (5), for a variety of complex reasons (6–8). There is a need to develop effective strategies to support people living with overweight and obesity, given their close association with a range of chronic health conditions and increased risks of developing metabolic diseases (2). Primary health care has an important role to play in managing chronic conditions, as the most frequent point of contact with the health system for most patients (9–11). These ongoing relationships facilitate the emotional support needed in this area. Talking with GPs and nurses may also be perceived as less stigmatizing than with specialist providers (12). However, there is a mismatch between the perceived importance of this and current practice (13). Discussions of healthy weight management in primary health care do not occur as frequently as desirable (14–16). Despite patient interest in input from primary care (17), only 25% of patients in Scotland (18) and 10–42% of Australian patients with overweight or obesity (19) report discussing weight with their GP. There are clearly opportunities for greater and more effective engagement in the area of weight management. Clinicians report a need for simple tools and training in brief weight counselling (14,20–22), allowing them to provide appropriate support to patients with overweight or obesity in a non-stigmatizing manner (23). Referring patients to external intensive weight management programmes has been the focus of other research in this area (24,25), but brief interventions for weight loss in primary care have also been shown to be effective (26). Use of such interventions is analogous to similar strategies for alcohol, mental health and low back pain (27–30), where regular, brief conversations have been successful, either within the standard consultation or with slightly longer consultation formats. A brief opportunistic intervention for use in NZ primary care was developed on the basis of previous research involving GPs, nurses and patients (31,32) and tested in several general practices establishing acceptability to both clinicians and patients (33). For the current study, this ultra brief approach was refined and updated in line with the NZ Ministry of Health clinical guidelines for weight management (34) with the specific aim of facilitating frequent, positive conversations between clinicians and patients about healthy weight. This approach (FABS: Food, Activity, Behaviour, Support) was trialled in five general practices in the lower North Island of New Zealand by a Primary Health Organization (PHO). The aim of this study was to investigate the feasibility of using this brief opportunistic approach with adult patients in routine general practice consultations during the pilot period, as well as its effectiveness in facilitating healthy weight conversations. Methods This study used a sample of anonymized quantitative practice data about a healthy weight conversation approach collected over a 4-month period in 2018. Setting Five general practices with a record of routinely tracking weight and height for a minimum of 50% of enrolled adult populations over the previous 5 years were purposefully recruited within one region of NZ. Practices were selected to reflect different geographical locations, populations and practice sizes within the greater Wellington region. Participants All 36 clinicians in the general practices were invited to participate in the training session and to use the approach. They were trained to use the intervention opportunistically within routine consultations with any adult patient with a body mass index of over 28 kg/m2, identified either from their records or from calculation within the consultation. Description of the approach The key content was developed from previous work and adapted to four topic areas: Food, Activity, Behaviour and Support which gave the name ‘FABS’. The FABS approach has a whole-practice focus to achieve a ‘water dripping on a stone’ effect through repeated small consistent and supportive messages with any clinician a patient sees, as and when appropriate, as a part of routine consultations. There are three elements to the approach: staff training, a screening template and a tear-off pad for use as a prompt for the clinician and/or as a patient handout. Training sessions of 45–120 minutes were conducted onsite with individual practices and were delivered by a multidisciplinary team: a GP, an interactional sociolinguist and a public health specialist (all part of the research team). All staff were encouraged to attend the training sessions, including GPs, primary care nurses, practice managers and administrative staff. The training included current thinking around weight management, conversational strategies for raising the topic of weight management in routine consultations and advice on appropriate non-stigmatizing language and approaches. Key conversational strategies developed from our previous research were to introduce the topic with delicacy, not to pursue the topic in the face of opposition or lack of interest by the patient (31), and the importance of eliciting patient perspectives on weight management (35). The tear-off pad covered the four ‘FABS’ topic areas, each with three to five bullet point prompts. These were not intended to be delivered all at once; training encouraged a focus on one or two points relevant to the patient in a single consultation, with points to be revisited or added to as opportunities arose and as appropriate. The screening template was integrated with the Patient Management System (PMS) computer dashboard. This enabled clinicians to record the conversations in a structured way on the patient record, ticking which topics had been discussed. The outcome section enabled patients to be classified as ‘pre-contemplative’ (not open to discussion at that point), ‘contemplative’ (thinking about the topic) or ‘action’ (key messages were given and positively received by the patient), based on the transtheoretical model of change (36). The template could be opened and added to multiple times by any clinician, recording multiple discussions of topics. The overall use of the template for an individual patient could be monitored by the practice or clinicians with a chart function which tracked engagement over time, as well as interactions with multiple clinicians. The intervention was used over a 4-month period, with a small financial incentive from the PHO for practices to take part and participate in the training, data input and feedback. Data collection and analysis The feasibility and effectiveness of the approach in terms of facilitating conversation was measured through number of clinicians using the template, number of consultations it was used with and number of topics raised, with supplementary qualitative feedback via a survey and interviews with six participants. Our focus was on how effective the approach was in supporting healthy weight conversations and did not measure behaviour or weight change. Anonymized practice data were captured via entries into the FABS template by clinicians in business as usual conditions. Patients were not directly recruited to participate as the analysis used anonymized routine data. The capture of data through the PMS meant all entries were collated under the name of the patient’s GP without indicating use of the template by other clinicians (usually nurses). All clinicians in the practices were invited to respond to a simple online clinician survey, whether or not they had used the FABS approach and screening tool. The interviews were conducted with two GPs and four patients as part of a small-scale separate related study (37), in which GPs using the intervention and their patients were asked to consent to video recording of their consultation. Participants in each recorded consultation were interviewed soon after the recording about how the consultation went and the topic of weight. GPs were also asked general questions about barriers and enablers to using the intervention and their reaction to the FABS approach. Interviews with patients included questions on their reaction to how the topic of healthy weight was raised with them. Descriptive analysis was conducted of the demographic characteristics of the patients with whom the template was used, as well as the use of the template. A framework analysis of interview responses was conducted. Results Practice demographics The practices ranged in size between 4000 and 11,000 enrolled patients. Three were suburban, one was urban and one was rural with between 3 and 10 GPs in each practice. Clinician demographics Twenty-seven GPs in the five pilot practices (75%) used the intervention: 12 men and 15 women. FABS was used by all or almost all GPs in three of the practices and by half of the GPs in the other two practices, most of whom used it for the entire pilot period (See Supplementary Table 1 for more detail). Patient demographics The profile of the ‘FABS’ patients is similar to the overall enrolled population of each practice in terms of gender, ethnicity and socio-economic status, with the age profile differing as expected given the selection criteria (See Supplementary Table 2 for more detail). There was a gender imbalance towards men in one practice and towards women in another, despite the enrolled populations being balanced for gender. Despite clinicians being guided to use this approach with adult patients, the data show 7 clinicians used it with 10 patients under the age of 15 years. The demographic profile of the patients is shown in Table 1 (Demographic data was not always entered by the GP, resulting in some missing data). Table 1. Demographic characteristics of patients receiving a healthy weight intervention in five primary health care practices in New Zealand (2018) Practice . . 1 . 2 . 3 . 4 . 5 . Number of patient consults 830 162 45 105 53 465 N (%) % % % % % Gender  Male 387 (47) 51 52 62 33 43  Female 433 (52) 48 47 38 66 56  Not recorded 10 (1) 1 1 0 1 1 Ethnicity  Asian 71 (9) 6 2 15 8 9  European 634 (76) 83 80 57 70 79  Māori 48 (6) 7 16 11 7 3  Pacific 47 (6) 3 0 8 11 6  Other 18 (2) 1 0 10 2 1  Unknown/ not recorded 12 (1) 0 2 0 2 2 Age  0–14a 10 (1) 1 2 2 2 1  15–24 46 (6) 5 4 6 2 6  25–44 161 (19) 19 16 14 34 20  45–64 372 (45) 49 47 47 42 43  65+ 231 (28) 25 29 30 19 29  Not recorded 10 (1) 1 2 1 2 1 Quintileb  1 278 (33) 35 4 25 26 39  2 217 (26) 27 18 38 34 23  3 156 (19) 18 11 17 13 21  4 98 (12) 14 38 12 17 8  5 56 (3) 4 27 4 8 6  Not recorded 25 (3) 2 2 4 2 3 Practice . . 1 . 2 . 3 . 4 . 5 . Number of patient consults 830 162 45 105 53 465 N (%) % % % % % Gender  Male 387 (47) 51 52 62 33 43  Female 433 (52) 48 47 38 66 56  Not recorded 10 (1) 1 1 0 1 1 Ethnicity  Asian 71 (9) 6 2 15 8 9  European 634 (76) 83 80 57 70 79  Māori 48 (6) 7 16 11 7 3  Pacific 47 (6) 3 0 8 11 6  Other 18 (2) 1 0 10 2 1  Unknown/ not recorded 12 (1) 0 2 0 2 2 Age  0–14a 10 (1) 1 2 2 2 1  15–24 46 (6) 5 4 6 2 6  25–44 161 (19) 19 16 14 34 20  45–64 372 (45) 49 47 47 42 43  65+ 231 (28) 25 29 30 19 29  Not recorded 10 (1) 1 2 1 2 1 Quintileb  1 278 (33) 35 4 25 26 39  2 217 (26) 27 18 38 34 23  3 156 (19) 18 11 17 13 21  4 98 (12) 14 38 12 17 8  5 56 (3) 4 27 4 8 6  Not recorded 25 (3) 2 2 4 2 3 aThe intervention is targeted to adults but was used in a small number of consultations with children. bA measure of socio-economic deprivation in New Zealand: Quintile 1 represents people living in the least deprived 20% of census area units; Quintile 5 represents people living in the most deprived 20% of census area units. Open in new tab Table 1. Demographic characteristics of patients receiving a healthy weight intervention in five primary health care practices in New Zealand (2018) Practice . . 1 . 2 . 3 . 4 . 5 . Number of patient consults 830 162 45 105 53 465 N (%) % % % % % Gender  Male 387 (47) 51 52 62 33 43  Female 433 (52) 48 47 38 66 56  Not recorded 10 (1) 1 1 0 1 1 Ethnicity  Asian 71 (9) 6 2 15 8 9  European 634 (76) 83 80 57 70 79  Māori 48 (6) 7 16 11 7 3  Pacific 47 (6) 3 0 8 11 6  Other 18 (2) 1 0 10 2 1  Unknown/ not recorded 12 (1) 0 2 0 2 2 Age  0–14a 10 (1) 1 2 2 2 1  15–24 46 (6) 5 4 6 2 6  25–44 161 (19) 19 16 14 34 20  45–64 372 (45) 49 47 47 42 43  65+ 231 (28) 25 29 30 19 29  Not recorded 10 (1) 1 2 1 2 1 Quintileb  1 278 (33) 35 4 25 26 39  2 217 (26) 27 18 38 34 23  3 156 (19) 18 11 17 13 21  4 98 (12) 14 38 12 17 8  5 56 (3) 4 27 4 8 6  Not recorded 25 (3) 2 2 4 2 3 Practice . . 1 . 2 . 3 . 4 . 5 . Number of patient consults 830 162 45 105 53 465 N (%) % % % % % Gender  Male 387 (47) 51 52 62 33 43  Female 433 (52) 48 47 38 66 56  Not recorded 10 (1) 1 1 0 1 1 Ethnicity  Asian 71 (9) 6 2 15 8 9  European 634 (76) 83 80 57 70 79  Māori 48 (6) 7 16 11 7 3  Pacific 47 (6) 3 0 8 11 6  Other 18 (2) 1 0 10 2 1  Unknown/ not recorded 12 (1) 0 2 0 2 2 Age  0–14a 10 (1) 1 2 2 2 1  15–24 46 (6) 5 4 6 2 6  25–44 161 (19) 19 16 14 34 20  45–64 372 (45) 49 47 47 42 43  65+ 231 (28) 25 29 30 19 29  Not recorded 10 (1) 1 2 1 2 1 Quintileb  1 278 (33) 35 4 25 26 39  2 217 (26) 27 18 38 34 23  3 156 (19) 18 11 17 13 21  4 98 (12) 14 38 12 17 8  5 56 (3) 4 27 4 8 6  Not recorded 25 (3) 2 2 4 2 3 aThe intervention is targeted to adults but was used in a small number of consultations with children. bA measure of socio-economic deprivation in New Zealand: Quintile 1 represents people living in the least deprived 20% of census area units; Quintile 5 represents people living in the most deprived 20% of census area units. Open in new tab Clinician uptake The number of clinicians using the intervention (27 out of 36) shows a relatively high level of uptake. While most of these are likely to have been GPs, a number of nurses also used the approach (according to survey data). The intervention was used in 830 patient consultations with 757 patients. Seventy-six per cent of consultations were with patients of European background with smaller numbers of Asian, indigenous Māori and Pacific ethnicity, and 59% of higher socio-economic status (quintiles 1 and 2). The template was opened a total of 862 times over the 4-month period. This equates to approximately twice per day per practice. It was used consistently throughout the time. Topic coverage All topics in the FABS intervention were raised during the 4 months, however, some were raised much more frequently than others. The ranked distribution of topics selected is shown in Table 2. Table 2. Ranking of healthy weight topics ticked on a screening tool in five primary health care practices in New Zealand (2018) Topic . Explanation . Number of times raised . % of total . ACTIVITY - Physical Add short, physical activities into your daily routine great for wellbeing, heart health and mood 581 23 FOOD - Fat, Salt, Sugar Go for unsaturated fats, low salt, little or no sugar. 417 17 FOOD - Portion Size Reduce portion sizes, use a smaller plate for food and limit snacking. 381 15 ACTIVITY - Move Move more, sit less, sleep well. 364 15 FOOD - Drinks Drink more water, less alcohol and fewer sugary drinks 215 9 FOOD - Variety Add variety – different colours and types, more plant-based foods. 206 8 ACTIVITY - Sleep Aim for a regular sleep routine, 7 – 8 hours is generally recommended. 151 6 SUPPORT - Self-care Be kind to yourself – what makes you feel happy and relaxed? 134 5 SUPPORT - Stress Reflect on any stress in your life and how it affects your eating, drinking and sleep patterns 102 4 BEHAVIOUR - Red Flags? Identify your red flags – food and exercise challenges, stress 68 3 SUPPORT - Support Family, whanau, friends’ support is great for our overall wellbeing, harness these for a healthy weight. 55 2 BEHAVIOUR - One Step Take one step at a time, small changes to healthier food, drink, sleep and activity can give you lasting benefits. 34 1 BEHAVIOUR - Green Flags? Identify your green flags – things you can change to support a healthy weight. 32 1 ACTIVITY - Green Rx Is a green prescription suitable for you? 28 1 Topic . Explanation . Number of times raised . % of total . ACTIVITY - Physical Add short, physical activities into your daily routine great for wellbeing, heart health and mood 581 23 FOOD - Fat, Salt, Sugar Go for unsaturated fats, low salt, little or no sugar. 417 17 FOOD - Portion Size Reduce portion sizes, use a smaller plate for food and limit snacking. 381 15 ACTIVITY - Move Move more, sit less, sleep well. 364 15 FOOD - Drinks Drink more water, less alcohol and fewer sugary drinks 215 9 FOOD - Variety Add variety – different colours and types, more plant-based foods. 206 8 ACTIVITY - Sleep Aim for a regular sleep routine, 7 – 8 hours is generally recommended. 151 6 SUPPORT - Self-care Be kind to yourself – what makes you feel happy and relaxed? 134 5 SUPPORT - Stress Reflect on any stress in your life and how it affects your eating, drinking and sleep patterns 102 4 BEHAVIOUR - Red Flags? Identify your red flags – food and exercise challenges, stress 68 3 SUPPORT - Support Family, whanau, friends’ support is great for our overall wellbeing, harness these for a healthy weight. 55 2 BEHAVIOUR - One Step Take one step at a time, small changes to healthier food, drink, sleep and activity can give you lasting benefits. 34 1 BEHAVIOUR - Green Flags? Identify your green flags – things you can change to support a healthy weight. 32 1 ACTIVITY - Green Rx Is a green prescription suitable for you? 28 1 Open in new tab Table 2. Ranking of healthy weight topics ticked on a screening tool in five primary health care practices in New Zealand (2018) Topic . Explanation . Number of times raised . % of total . ACTIVITY - Physical Add short, physical activities into your daily routine great for wellbeing, heart health and mood 581 23 FOOD - Fat, Salt, Sugar Go for unsaturated fats, low salt, little or no sugar. 417 17 FOOD - Portion Size Reduce portion sizes, use a smaller plate for food and limit snacking. 381 15 ACTIVITY - Move Move more, sit less, sleep well. 364 15 FOOD - Drinks Drink more water, less alcohol and fewer sugary drinks 215 9 FOOD - Variety Add variety – different colours and types, more plant-based foods. 206 8 ACTIVITY - Sleep Aim for a regular sleep routine, 7 – 8 hours is generally recommended. 151 6 SUPPORT - Self-care Be kind to yourself – what makes you feel happy and relaxed? 134 5 SUPPORT - Stress Reflect on any stress in your life and how it affects your eating, drinking and sleep patterns 102 4 BEHAVIOUR - Red Flags? Identify your red flags – food and exercise challenges, stress 68 3 SUPPORT - Support Family, whanau, friends’ support is great for our overall wellbeing, harness these for a healthy weight. 55 2 BEHAVIOUR - One Step Take one step at a time, small changes to healthier food, drink, sleep and activity can give you lasting benefits. 34 1 BEHAVIOUR - Green Flags? Identify your green flags – things you can change to support a healthy weight. 32 1 ACTIVITY - Green Rx Is a green prescription suitable for you? 28 1 Topic . Explanation . Number of times raised . % of total . ACTIVITY - Physical Add short, physical activities into your daily routine great for wellbeing, heart health and mood 581 23 FOOD - Fat, Salt, Sugar Go for unsaturated fats, low salt, little or no sugar. 417 17 FOOD - Portion Size Reduce portion sizes, use a smaller plate for food and limit snacking. 381 15 ACTIVITY - Move Move more, sit less, sleep well. 364 15 FOOD - Drinks Drink more water, less alcohol and fewer sugary drinks 215 9 FOOD - Variety Add variety – different colours and types, more plant-based foods. 206 8 ACTIVITY - Sleep Aim for a regular sleep routine, 7 – 8 hours is generally recommended. 151 6 SUPPORT - Self-care Be kind to yourself – what makes you feel happy and relaxed? 134 5 SUPPORT - Stress Reflect on any stress in your life and how it affects your eating, drinking and sleep patterns 102 4 BEHAVIOUR - Red Flags? Identify your red flags – food and exercise challenges, stress 68 3 SUPPORT - Support Family, whanau, friends’ support is great for our overall wellbeing, harness these for a healthy weight. 55 2 BEHAVIOUR - One Step Take one step at a time, small changes to healthier food, drink, sleep and activity can give you lasting benefits. 34 1 BEHAVIOUR - Green Flags? Identify your green flags – things you can change to support a healthy weight. 32 1 ACTIVITY - Green Rx Is a green prescription suitable for you? 28 1 Open in new tab The top ranked topic was physical activity, followed by two food-related topics. Portion size was ranked third in frequency, although it was the most frequently mentioned topic in two practices (1 and 4). Overall, however, activity-related messages made up two of the top three messages in all practices (See Supplementary Figure S1 for detail.). There was also considerable variation between clinicians within practices as to which topics were raised most often, as shown in Figure 1, which shows the distribution of topics for three clinicians. Figure 1. Open in new tabDownload slide Healthy weight (FABS) topics raised by three individual primary care clinicians in New Zealand (2018). Figure 1. Open in new tabDownload slide Healthy weight (FABS) topics raised by three individual primary care clinicians in New Zealand (2018). Number of topics raised per consultation Despite the advice in training sessions to cover only 1 or 2 topics per consultation, there was wide variety between practices and within practices in this regard, ranging from 1 to 14 topics raised in a single consultation. Clinicians in two practices (1 and 5) followed the advice to raise only one to two topics per consultation most closely, but others tended to discuss a larger number of topics than suggested. Again, there was also variation between clinicians within a practice. Multiple use with individual patients Sixty-three patients received the intervention more than once, although most of these were seen by a single GP in Practice 5 (76%; n = 48). Most of this group (n = 56) received the intervention twice, with seven receiving it over three or four visits, mostly spaced 2–3 months apart. Table 3 shows which topics were repeated or added in subsequent consultations. Physical activity was the topic most often repeated and was also more likely to be repeated than added. Sleep was a topic that was more likely to be added in later. Table 3. Number of healthy weight topics repeated or added in a later consult in five primary health care practices in New Zealand (2018) Topics . Added . Repeated . FOOD - Portion Size 7 9 FOOD - Variety 2 2 FOOD - Drinks 9 2 FOOD - Fat, Salt, Sugar 14 14 ACTIVITY - Move 13 6 ACTIVITY - Physical 11 30 ACTIVITY - Sleep 12 2 ACTIVITY - Green Rx 0 0 BEHAVIOUR - One Step 0 0 BEHAVIOUR - Green Flags? 3 0 BEHAVIOUR - Red Flags? 2 2 SUPPORT - Self-care 4 2 SUPPORT - Stress 6 1 SUPPORT - Support 2 2 Total 85 72 Topics . Added . Repeated . FOOD - Portion Size 7 9 FOOD - Variety 2 2 FOOD - Drinks 9 2 FOOD - Fat, Salt, Sugar 14 14 ACTIVITY - Move 13 6 ACTIVITY - Physical 11 30 ACTIVITY - Sleep 12 2 ACTIVITY - Green Rx 0 0 BEHAVIOUR - One Step 0 0 BEHAVIOUR - Green Flags? 3 0 BEHAVIOUR - Red Flags? 2 2 SUPPORT - Self-care 4 2 SUPPORT - Stress 6 1 SUPPORT - Support 2 2 Total 85 72 Open in new tab Table 3. Number of healthy weight topics repeated or added in a later consult in five primary health care practices in New Zealand (2018) Topics . Added . Repeated . FOOD - Portion Size 7 9 FOOD - Variety 2 2 FOOD - Drinks 9 2 FOOD - Fat, Salt, Sugar 14 14 ACTIVITY - Move 13 6 ACTIVITY - Physical 11 30 ACTIVITY - Sleep 12 2 ACTIVITY - Green Rx 0 0 BEHAVIOUR - One Step 0 0 BEHAVIOUR - Green Flags? 3 0 BEHAVIOUR - Red Flags? 2 2 SUPPORT - Self-care 4 2 SUPPORT - Stress 6 1 SUPPORT - Support 2 2 Total 85 72 Topics . Added . Repeated . FOOD - Portion Size 7 9 FOOD - Variety 2 2 FOOD - Drinks 9 2 FOOD - Fat, Salt, Sugar 14 14 ACTIVITY - Move 13 6 ACTIVITY - Physical 11 30 ACTIVITY - Sleep 12 2 ACTIVITY - Green Rx 0 0 BEHAVIOUR - One Step 0 0 BEHAVIOUR - Green Flags? 3 0 BEHAVIOUR - Red Flags? 2 2 SUPPORT - Self-care 4 2 SUPPORT - Stress 6 1 SUPPORT - Support 2 2 Total 85 72 Open in new tab Clinician and patient feedback Survey data Eight clinicians (GPs and nurses) from three of the five practices completed the online survey, seven of whom had attended the training session and had used the FABS approach for 2 months or more on a regular basis. All rated the approach ‘very easy’ or ‘relatively easy’ to use. Six of the eight rated it ‘neutral’ to ‘easy’ in terms of incorporating the approach into consultations and raising the topic. Five intended to continue using the intervention in some form. Most clinicians (seven out of eight) reported raising the topic of weight more frequently with FABS and felt that it was easier to record what had been discussed (six out of eight). There was variation in suggestions for wider rollout: improving the screening template (n = 3), further training (n = 2) and developing App versions of the handout (n = 2). The main reasons given by those clinicians who did not use the screening template were forgetting to use it and the time pressure of 15-minute appointments. Interview data Supplementary data were obtained from interviews with two GPs and four patients who consented to their consultations being video recorded and to a brief interview for a related study. Illustrative quotes are shown in Table 4. Table 4. Illustrative quotes from six participant interviews within five primary health care practices in New Zealand (2018) Quotes from clinician interviews . Quote 1: I think it’s been particularly useful in that we talk about diet and exercise all the time, but I don’t think I ever talk to a patient about that lack of sleep can have on your weight. …until there was a little tool in front of me, I went oh! ... that was the first time I had ever connected those two things. (GP07) Quote 2: All these guys I’ve kind of known before, you know. (GP37) Quote 3: So ((NAME-PT))’s been a patient of mine for a number of years now, so I know ((NAME-PT)) very well. (GP07) Quote 4: They haven’t come about their weight, generally speaking and it’s my agenda that I want to talk to them about their weight. And I want to do that within 15 minutes. That’s the problem. It’s not the tool, it’s the time. (GP07) Quote 5: it wouldn’t be the right thing to do. Her weight is like her least of her problems (GP37) Quote 6: I think that she would take a lot of consultations. You have to reiterate this… for it to make a difference…. It’s something that is an ongoing process too… she’s got a long way to go. (GP37) Quotes from patient interviews . Quote 7: I am really quite happy to talk to my GP about anything at all… it was appropriate today, because we’d been talking about my knees....and about the problems the excess weight can cause... so it was an appropriate time for her to bring it up. (GP07-08) Quote 8: RS:And how did you feel about those extra topics being raised? PT:Oh … I like ... to cover those things. Even if I’ve been over them before. (GP07-09) Quote 9: RS:So were you comfortable with him raising the topic with you? PT:Yes, yes. Yeah. Yeah. Definitely. (GP37-01) Quotes from clinician interviews . Quote 1: I think it’s been particularly useful in that we talk about diet and exercise all the time, but I don’t think I ever talk to a patient about that lack of sleep can have on your weight. …until there was a little tool in front of me, I went oh! ... that was the first time I had ever connected those two things. (GP07) Quote 2: All these guys I’ve kind of known before, you know. (GP37) Quote 3: So ((NAME-PT))’s been a patient of mine for a number of years now, so I know ((NAME-PT)) very well. (GP07) Quote 4: They haven’t come about their weight, generally speaking and it’s my agenda that I want to talk to them about their weight. And I want to do that within 15 minutes. That’s the problem. It’s not the tool, it’s the time. (GP07) Quote 5: it wouldn’t be the right thing to do. Her weight is like her least of her problems (GP37) Quote 6: I think that she would take a lot of consultations. You have to reiterate this… for it to make a difference…. It’s something that is an ongoing process too… she’s got a long way to go. (GP37) Quotes from patient interviews . Quote 7: I am really quite happy to talk to my GP about anything at all… it was appropriate today, because we’d been talking about my knees....and about the problems the excess weight can cause... so it was an appropriate time for her to bring it up. (GP07-08) Quote 8: RS:And how did you feel about those extra topics being raised? PT:Oh … I like ... to cover those things. Even if I’ve been over them before. (GP07-09) Quote 9: RS:So were you comfortable with him raising the topic with you? PT:Yes, yes. Yeah. Yeah. Definitely. (GP37-01) Open in new tab Table 4. Illustrative quotes from six participant interviews within five primary health care practices in New Zealand (2018) Quotes from clinician interviews . Quote 1: I think it’s been particularly useful in that we talk about diet and exercise all the time, but I don’t think I ever talk to a patient about that lack of sleep can have on your weight. …until there was a little tool in front of me, I went oh! ... that was the first time I had ever connected those two things. (GP07) Quote 2: All these guys I’ve kind of known before, you know. (GP37) Quote 3: So ((NAME-PT))’s been a patient of mine for a number of years now, so I know ((NAME-PT)) very well. (GP07) Quote 4: They haven’t come about their weight, generally speaking and it’s my agenda that I want to talk to them about their weight. And I want to do that within 15 minutes. That’s the problem. It’s not the tool, it’s the time. (GP07) Quote 5: it wouldn’t be the right thing to do. Her weight is like her least of her problems (GP37) Quote 6: I think that she would take a lot of consultations. You have to reiterate this… for it to make a difference…. It’s something that is an ongoing process too… she’s got a long way to go. (GP37) Quotes from patient interviews . Quote 7: I am really quite happy to talk to my GP about anything at all… it was appropriate today, because we’d been talking about my knees....and about the problems the excess weight can cause... so it was an appropriate time for her to bring it up. (GP07-08) Quote 8: RS:And how did you feel about those extra topics being raised? PT:Oh … I like ... to cover those things. Even if I’ve been over them before. (GP07-09) Quote 9: RS:So were you comfortable with him raising the topic with you? PT:Yes, yes. Yeah. Yeah. Definitely. (GP37-01) Quotes from clinician interviews . Quote 1: I think it’s been particularly useful in that we talk about diet and exercise all the time, but I don’t think I ever talk to a patient about that lack of sleep can have on your weight. …until there was a little tool in front of me, I went oh! ... that was the first time I had ever connected those two things. (GP07) Quote 2: All these guys I’ve kind of known before, you know. (GP37) Quote 3: So ((NAME-PT))’s been a patient of mine for a number of years now, so I know ((NAME-PT)) very well. (GP07) Quote 4: They haven’t come about their weight, generally speaking and it’s my agenda that I want to talk to them about their weight. And I want to do that within 15 minutes. That’s the problem. It’s not the tool, it’s the time. (GP07) Quote 5: it wouldn’t be the right thing to do. Her weight is like her least of her problems (GP37) Quote 6: I think that she would take a lot of consultations. You have to reiterate this… for it to make a difference…. It’s something that is an ongoing process too… she’s got a long way to go. (GP37) Quotes from patient interviews . Quote 7: I am really quite happy to talk to my GP about anything at all… it was appropriate today, because we’d been talking about my knees....and about the problems the excess weight can cause... so it was an appropriate time for her to bring it up. (GP07-08) Quote 8: RS:And how did you feel about those extra topics being raised? PT:Oh … I like ... to cover those things. Even if I’ve been over them before. (GP07-09) Quote 9: RS:So were you comfortable with him raising the topic with you? PT:Yes, yes. Yeah. Yeah. Definitely. (GP37-01) Open in new tab One GP particularly commented on the usefulness of the FABS approach as a prompt to discuss less commonly raised issues connected to weight, such as sleep (Quote 1). The main enabler mentioned by both GPs for feeling comfortable raising the topic was the context of knowing the patient well from a long relationship (Quotes 2 and 3). Three main challenges to the approach were noted: time limitations (Quote 4), sensitivity to the patient agenda (Quote 4) and the appropriateness of raising the topic in the context of other patient issues (Quote 5). One GP commented on one key aspect of the FABS approach, the need for repeated conversations over time (Quote 6). The patients interviewed all gave positive feedback about how the topic of weight was raised with them in their consultation (Quotes 7–9), with one mentioning the link to their own agenda as being important (Quote 7). Conclusions This study demonstrated that brief discussion of healthy weight can be incorporated into routine primary health care consultations in different practice settings and by different clinicians. This can be achieved without significant impact on the length or other business of the consultation itself or on the clinician–patient relationship. Clinicians and patients both responded positively to the approach. While conducted within a local New Zealand setting, we feel there are sufficient commonalities in primary care practice in many other Organisation for Economic Co-operation and Development countries for the findings to have international relevance. A key benefit of the FABS approach is that it is a very brief intervention which is able to be used within routine consultations. This distinguishes it from other primary care obesity approaches that refer to weight loss programmes (24,25,38), or provide much more intensive focused interventions (38,39). Brief approaches have been found effective in various areas of primary health care (28–30), although few of those found in the obesity literature can be described as truly brief. The approach used was acceptable to both men and women. While this is important for global trends and predictions of more women than men living with obesity by 2025 (22), acceptability to men is also important since in some countries including NZ more men than women live with obesity (21). The variation between practices and among clinicians (of both frequency of topics raised and number of topics raised per consultation) demonstrates the flexibility of the approach in terms of tailoring to local issues or concerns. Interestingly, the raising of multiple topics in single consultations is at odds with reported lack of time in consultations (and was also contrary to the training recommendations). The top ranking of topics relating to physical activity is consistent with earlier research indicating that clinicians are more comfortable raising this topic or believe this is the main cause of obesity (40), notwithstanding its relevance for some patients. When food-related messages were delivered, the high ranking of the fat/sugar/salt topic compared to portion size may reflect the fact that sugar currently has a high profile in the media (41). The approach was used with some patients over multiple consultations even within the short timeframe of 4 months. The focus on clinicians having short conversations raising only one or two points in any one consultation facilitates this, reinforcing messages or adding less frequently mentioned topics, such as sleep, that might otherwise get missed. The tear-off A5 pad used by clinicians and given to patients was a low-cost resource that was positively received. Further work would be required to establish if this was the most appropriate resource or whether other mediums (such as apps) should also be developed (as well or instead). While there were some reported challenges with the use of FABS (time constraints, patient agendas and competing issues), the approach was found to be feasible within general practice where established patient relationships appear to be important, in keeping with other research (33,40). If the FABS approach is to be used more widely, the content and delivery of the health professional training would need to be refined and tailored to local conditions, particularly to specific ethnic groups who are disproportionately affected by weight issues, preferably through co-design processes. Scalable modes of training delivery such as web-based self-access resources combined with face-to-face training would also be required. The strengths of this study were that it was conducted within routine consultations in a range of GP practices and with a very brief intervention. While intended for use with adult patients, we have reported the limited use made of it with younger patients by some clinicians to illustrate the pragmatic nature of introducing innovations into primary care settings. Limitations include the small-scale study, and the fact that the number of topics discussed was self reported (i.e. clinician use of the screening tool rather than direct evidence such as video recording). Another limitation arose from a technical constraint of the screening template which was linked to the patient’s GP and thus did not distinguish use by individual clinicians, making it impossible to break the data down by type of clinician. The patients involved in this study were not drawn from a representative sample of the NZ population and as a descriptive study, no statistical analyses were conducted. The supplementary qualitative data are based on a very small number of interviews. This study has demonstrated that it is possible to provide an infrastructure for healthy weight management within general practice so that patients receive supportive, non-stigmatizing and consistent messages around healthy behaviours on a regular basis, ‘like water dripping on a stone’. General practice is an appropriate site for this kind of intervention due to the ongoing relationships with patients, but there is a need for effective training and education to ensure the approach is delivered appropriately and effectively. Declaration Funding: This study was funded by Tū Ora Compass Health as part of a Ministry of Health project. Tū Ora Compass Health was responsible for the collection of practice data. The supplementary data are from a study funded by a University of Otago Research Grant (2018). Ethical approval: The study was approved by the University of Otago Human Ethics Committee (Health) (HD18/033 and HE18/005). Conflict of interest: SD is an employee of Tū Ora Compass Health, which might have an interest in the submitted work. Acknowledgements The authors gratefully acknowledge the primary care general practices that participated in the pilot intervention, in particular the clinicians and patients in whose consultations the intervention was delivered. The authors also thank Tū Ora Compass Health for their assistance, in particular Dipan Ranchhod (Senior Analyst) and Bronwen Warren (General Manager Clinical Services). References 1. NCD Risk Factor Collaboration . Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19· 2 million participants . Lancet 2016 ; 387 ( 10026 ): 1377 – 96 . Crossref Search ADS PubMed WorldCat 2. World Health Organization , Global Health Observatory. Prevalence of Obesity Amongst Adults, Aged 16+, 1975–2016, Both Sexes . 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Journal

Family Practice – Oxford University Press

Published: Nov 13, 2020

Keywords: physical activity; consultation; primary health care; weight maintenance regimens; new zealand; food; adult

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