Despite recent indications that the upward trend in childhood obesity is plateauing, its prevalence remains at historically high levels [1
]. Although childhood obesity affects around 6% (approximately 200,000) of all Australian children, very few of them receive treatment from their general practitioner or paediatrician [2
]. Effective evidence-based treatments remain scarce and are generally only available to small proportions of seriously obese children through tertiary care settings. Whilst prevention must ultimately be the main goal, there are already a large number of obese children who urgently require effective treatment if the consequences for their adult health – such as heart disease and diabetes, psychological morbidity, and massive excess health care costs – are to be avoided.
So far, the only healthcare setting that is consistently documented to reproducibly improve the body composition and health of obese children is the specialist obesity clinic, generally involving lifestyle advice, motivation and feedback provided by a multidisciplinary team over a year or more. Mean reductions in body mass index (BMI) z-score sustained to at least 12
months are typically around 0.3 [4
]; approximately 85% of children typically achieve at least some overall reduction in BMI z-score although only around 30% achieve the reduction of ≥0.5 [4
] that equates to definite reductions in fat mass [6
] and quantifiable improvements in risk factors for heart disease and diabetes [4
]. Unfortunately, although intervention appears more successful for younger children, the caseload of specialist obesity clinics is often typically skewed towards adolescents with significant psychological, social and family dysfunction for whom treatment is less effective [4
]. Furthermore, such clinics are inaccessible to almost all children. By our estimation the nine obesity clinics in children’s hospitals around Australia could see, at most, around 0.05% of affected Australian children each year, and it seems likely that other countries would have similar situations.
Therefore, as the only universally-accessible healthcare service available throughout childhood, general practice might seem the obvious healthcare setting to support the improvement, achievement and maintenance of healthy weight in children who are already overweight or obese. However, trials of obesity approaches in which treatment is initiated and carried out solely by general practitioners, with or without allied health services, have been extraordinarily disappointing to date both for adults [8
] and children [9
]. A new approach is therefore needed to augment the treatment of childhood obesity in primary care.
Nonetheless, there remain good reasons for optimism when considering general practice as a mode for the successful management of paediatric obesity. Firstly, this is where the majority of overweight/obese children present. In a study of 3000 Victorian primary school children, parents reported that 55% of overweight children had attended a GP once or twice in the preceding six months, and 22% three or more times [13
]. In two subsequent randomised controlled trials, we have also shown that: (1) general practitioners can and do take up training to offer a series of structured consultations using strategies for family lifestyle change, (2) that they are able to systematically identify children in the overweight and obese categories, (3) that families are willing for their children to be screened for BMI and not only engage, but persist, with their general practitioner, and (4) that this approach does not appear to be harmful for overweight or mildly obese children [10
]. GPs are very clear that the management of childhood obesity falls within their role [15
] and with training they can feel comfort and competent in this area [16
The literature on shared-care approaches incorporating primary and specialist partnerships is relatively limited but encouraging in achieving similar [17
] or better [19
] disease outcomes with important ancillary outcomes such as increased satisfaction [20
] and reduced waiting times [21
]. For instance, an adult rheumatoid arthritis trial demonstrated higher quality-adjusted life-years for the shared-care than the aggressive arm [18
], while a shared-care intervention for patients newly diagnosed with cancer increased general practitioner contact and positively influenced patients’ attitudes toward the healthcare system [17
]; in neither trial was the disease outcome poorer in the shared-care arm. However, few shared-care trials have focused on children, and none on childhood obesity.
Given the potential benefits of health information technology to general practice [22
], the Australian government has prioritised its use and value [23
] with the result that, by 2005, 80% had broadband access and nearly 90% used a computer for clinical purposes [24
], and is most likely close to 100% as of 2011. Some health information technology features are already nearly universally (eg prescribing) or frequently (eg accessing patient educational material) used, but far fewer general practitioners (<20%) are accessing computerised clinical information or using online decision support during consultations [24
]. It is clear that e-health has both promise and limitations [25
] and that the potential will not be actualised without carefully designing e-health initiatives into the primary care process. Health information technology could present an excellent mechanism to enhance shared-care models.
The HopSCOTCH (Shared Care Obesity Trial in Children) randomised trial is the first to our knowledge to study the efficacy of a general-practitioner based, shared-care model in reducing obesity in children – a population relatively underserved by evidence-based approaches [26
]. The intervention needs to be developed in such a way that it could be widely implemented with consistency and sustainability, but with relatively little training. Underpinning this would be a very practical software platform that would provide standalone guidance and information to GPs while also enhancing primary-specialty care partnerships. The software would also support continuing practice improvement activities and the individual practitioner feedback that has proved useful in many fields [27
]. Essentially, we hope to replicate the effectiveness of the specialty obesity clinic in the general practice setting, with attention to feasibility, sustainability and a wider and more systematic availability.