At the Melting Pot on 20 February my head found itself drifting to the complexity of general practice where I have worked for 25 years.
With individual patients, trying to deal with obesity is often unfruitful. It’s easy to talk about lifestyle, especially when GPs, among others, have been paid to measure and advise. But as a practitioner, all I felt I could do was impart some fairly obvious advice, offer drugs (now mostly withdrawn or ineffective), or refer for drastic surgery. Unsurprisingly, I’d be left wondering if any of this was helpful.
Surely, if there was a simple answer, there wouldn’t be such a thriving diet industry? When an obese person tips into diabetes, the health consequences are significant. However, diabetes, at least in the early years, is reversible if a healthy weight can be regained. So, given the limited tools at my disposal, was there anything I could do to make a difference?
Back to the Melting Pot, and our topic, complexity (as you may have guessed), and our speaker, Harry Rutter of the London School of Hygiene and Tropical Medicine. Harry explained that the classic approach to clinical research uses the ‘gold standard’ Double Blind Placebo-Controlled Trial. This compares a single intervention against a dummy one and works well in testing hypotheses with a linear cause-effect. This can then inform a single intervention which an expert can control (such as a new drug). It is elegant and simple.
He described such a trial. Obese patients were invited to take part in a structured exercise program to help them lose weight. They became more active but the weight loss was not significant because they compensated by eating more. However, we know that active populations are less likely to be obese. Just because the intervention didn’t work, we can’t extrapolate that the exercise trainer was to blame, or that exercise does not matter.
This research population is an example of a complex adaptive system; making a change in one part of the system results in an adaptive response somewhere else so that overall change is minimised. Instinctively, we would recognise that, though we are individuals, we exist in a society. Our health might be influenced not only by individual factors such as genes and lifestyle ‘choices’, but also by the constraints and opportunities in our built environment, of our socio-economic circumstances, our education, the political cycles and the norms of the groups we belong to.
But complex systems can be informed by logical frameworks to help design interventions. Harry described a project to increase breastfeeding rates in a locality. Evidence shows that breastfed babies are less likely to become obese children. The intervention involved recruiting cafés to become ‘breastfeeding friendly’ and supporting them with publicity and window stickers. After a year or so, the next phase would be to run a competition for the ‘Best Breastfeeding Café’. The goal was to help normalise breastfeeding in public and raise public awareness. If the ultimate outcome is to reduce the prevalence of obesity, this approach might seem unimpressive and slow. But it is still deliberate, supported by a logical framework. And it is low tech, cheap and adaptable. As Harry says, if you move 5% towards your goal every year, in 20 years you’ve got there.
Successive leaders and policy makers talk about prevention as if it’s a revelation. But without a real-world, sophisticated framework for understanding and taking action, we’re not going to have any impact on the ‘epidemic ‘ of obesity and diabetes.
I am left with a renewed sense of hope. Deliberate action can be taken if the system and its influences are understood. Lifestyle issues are not solely the responsibility of individual doctors and patients and a variety of insights and expertise is needed to address the complexities of population health. It will be interesting to see whether new models of care and STPs will be able to take on the challenges of population health through multi agency work, everyone playing their part whilst sharing a common framework.