Obesity and Diabetes in Vulnerable Populations: Reflection on Proximal and Distal Causes

This is such a thoughtful and comprehensive article reviewing so may varied contributions to the current epidemic of obesity and diabetes in vulnerable populations. I fully support Dr Candib’s recommendation for primary care clinicians to get out of the office and for health care institutions to reach out through community collaborations. Partnerships with community bring the vital community knowledge, experiences and voices to the table to develope appropriate interventions. Using community-based participatory research with shared decision making of community and researchers (1,2) promotes community relevant evaluation of interventions (3) and also promotes capacity building and sustainability past the end of research grants. I have had the experience of working with a community both as a family physician and within a community-based participatory research project at the same time. I believe they were highly complementary, but think I reached a greater number of people through the research project. As family physicians we have a high level of appropriate training to undertake this way of partnered research (4). 1.Jones L, Wells K. Strategies for academic and clinician engagement in community-participatory partnered research. JAMA 2007;297:407–410 2. Macaulay AC, Commanda L, Freeman WL, Gibson N, McCabe ML, Robbins CM, Twohig PL.Participatory Research maximised community and lay involvement. BMJ 1999;319;774-778 3.Green LW Making research relevant: if it is an evidence-based practice, where's the practice-based evidence? Fam. Practice Advance Access published on September 15, 2008 4.Macaulay AC. Promoting Participatory Research by Family Physicians Annals of Family Medicine 2007;5:557-560

Competing interests:   None declared

In her article (1), Lucy Candib argues for a syndemic orientation towards what is currently one of the largest public health challenges: excess body weight. Candib calls for action from clinicians (in particular family practitioners (FPs)) to use community-strategies to counteract the overweight epidemic caused by multiple factors.

We support her notion that FPs can play a vital role in this epidemic, ranging from individual guidance, through - if achievable - initiating local community-based projects. In this commentary, however, we would like to emphasize that FPs predominantly provide weight management in high risk groups, such as diabetes patients. In many countries, the continuity of care in Family Practice provides an ideal basis for long- term intervention beyond only high-risk groups (2). Furthermore, patients perceive FPs to be knowledgeable and reliable sources of lifestyle information and want FPs to have a role in weight management. Although busy day-to-day schedules leave FPs little time for such activities outside the core business (3), initiatives for multiprofessional teams to provide weight management services can bring relief on the long-term (4).

It may be very disappointing and/or discouraging for individual FPs to put large efforts into community-based activities outside their offices and to see little or no effect in the patients inside their offices. Since community-based approaches take a very long time to grow and their impact, while modest (at best) on the community level (5), varies largely among individuals. Also obesogenic factors like the food industry and fast-food trends are not likely to be changed by FPs.

So we urge FPs and other health professionals to take an active role. However, we strongly believe that it is most realistic to call for action from FPs as fore fighters inside their offices, on an individual/family level, and as supports on community level. In the end, change can only be made by individuals themselves, and exactly in this area FPs can contribute most.

Verheijden MW, PhD (1); Van Wayenburg CAM, MD (2); Van Binsbergen JJ, PhD MD (2) 1 TNO Quality of Life, PO Box 2215, 2301 CE Leiden, The Netherlands. 2 Department of General Practice, Radboud University Nijmegen Medical Centre, PO Box 9101 Internal postal code HAG 117, 6500 HB Nijmegen, The Netherlands.

(1) Candib LM. Obesity and diabetes in vulnerable populations: reflection on proximal and distal causes. Ann Fam Med 2007;5:547-556. (2) Verheijden MW, Bakx JC, Van Weel C, Van Staveren WA. Potentials and pitfalls for nutrition counselling in general practice. Eur J Clin Nutr 2005;59(suppl 1):S122-S129. (3) Hiddink GJ, Hautvast JG, Van Woerkum CM, Fieren CJ, Van ’t Hof MA. Nutrition guidance by primary-care physicians: perceived barriers and low involvement. Eur J Clin Nutr 1995;49(11):842- 51. (4) Gray DP. Dietary advice in British General Practice. Eur J Clin Nutr 1999;53(suppl 2):S3-S8. (5) Verheijden MW, Kok FJ. Public health impact of community-based nutrition and lifestyle interventions. Eur J Clin Nutr 2005;59(suppl):S66-S76.

Competing interests:   None declared