Dr Peymane Adab reviews the newly published NICE guideline on maintaining a healthy weight and preventing excess weight gain and the pivotal role of primary care
Read this article to learn more about:
- how maintaining a healthy weight can reduce the risk of chronic disease and premature death
- practical suggestions that can be used to promote weight maintenance and prevent excess weight gain
- the importance of tailoring advice to each individual to maximise the likelihood of behaviour change.
Obesity rates have increased year on year in the UK over the last 20 years, such that in 2013 over two thirds of men and 57% of women were overweight (BMI 25–29.9 kg/m2 or obese (BMI ≥30 kg/m2).1 Furthermore, cohort studies following up the same individuals have shown that most adults tend to gain weight over time, at a rate of 0.2 kg per year in the UK.2 Studies in other countries have shown that the increase in central adiposity (waist circumference) over time is even greater than that expected from observed changes in weight.3
Among children, the proportion classified as obese doubles during the primary school years, from 9.5% at age 4–5 years, to over 19% among 10–11 year olds.4 People from more disadvantaged backgrounds, and those from minority ethnic groups in the UK, are at highest risk.4
Adults who are overweight have an increased risk of developing chronic diseases, including diabetes, heart disease, and various cancers.5 There is no absolute BMI threshold for increasing risk; rates of diabetes are higher even among those of a healthy weight (BMI 18.5–24.9 kg/m2) compared with those who are 'underweight' (BMI <18.5 kg/m2).6 Life expectancy is reduced by up to 4 years for those with a BMI over 30 kg/m2, and up to 10 years for those with a BMI over 40 kg/m2—a comparable effect to that of smoking.7 Among children, those who are overweight have higher rates of cardiovascular risk factors than their healthy weight counterparts.8 Since obesogenic behaviours continue to adulthood, they also have increased risk of remaining overweight as adults,9 with the associated health consequences.
Furthermore, children as young as 7 years old who are overweight have a higher risk of premature mortality and chronic disease in adulthood compared with those who are non-overweight;10 this increased risk has been shown to be independent of their subsequent adult weight status.11 Childhood obesity can also adversely affect emotional and social outcomes,12 and it may also impact on educational attainment.13
The role of primary care
Once obesity is established, participation in lifestyle weight management interventions can be effective in achieving modest weight loss in adults14 and children15 who attend, although the effects tend to diminish over time. However, the majority of those individuals with obesity do not take up such services.16,17 Therefore preventive interventions are important for all patients, irrespective of weight status.
Most adults visit their GP at least once during the course of a year, and 98% of children are registered with a primary care practitioner.18 The primary care setting is therefore an ideal opportunity to assess and advise on approaches for weight maintenance in both adults and children.
One obstacle to GPs providing preventive advice may be a lack confidence in the effectiveness of preventive interventions.19,20 Furthermore, there is little experience on how to communicate messages to motivate behaviour change.
NICE Guideline 7, published in March 2015, on Maintaining a healthy weight and preventing excess weight gain among adults and children addresses some of these issues (see also Box 1, below).21 One of the related evidence reviews22 provides a summary of modifiable behaviours that are likely to affect healthy weight maintenance and weight gain. A second review23 explored the most effective ways to communicate information about modifiable behaviours related to healthy weight maintenance to adults and children.
|Box 1: NICE Accreditation Mark|
|NICE Guideline 7 on Maintaining a healthy weight and preventing excess weight gain among adults and children has been awarded the NICE Accreditation Mark.
This Mark identifies the most robustly produced guidance available. See evidence.nhs.uk/accreditation for further details.
Some of the key features of the recommendations relevant to primary care are outlined below. Given the tendency towards weight gain over time in most people, these messages are as important for people who are currently a healthy weight, as for those who are overweight.
What messages should be communicated to adults and children?
Advice on behaviours to prevent weight gain inevitably relates to a combination of increasing physical activity levels, reducing sedentary behaviours, and developing healthier dietary habits.21
In this respect, it is important to emphasise that achieving a balanced diet and physical activity habits does not imply that healthy eating can be neglected if one is physically active, and vice versa. Furthermore, it is prudent to discourage extreme behaviours, such as obsessive exercising or diets that are not sustainable in the longer term.21
It is also important to dispel some commonly held false beliefs around weight maintenance. Weight gain in adulthood, although common, is not inevitable.21 Adopting healthy eating habits and increasing levels of physical activity can prevent weight gain. However, there is no single dietary component, or particular type of physical activity that will solely contribute to weight maintenance; rather, a combination of approaches is always needed.21
Encouraging physical activity habits and reducing sedentary behaviours
Reviews of interventional studies suggest that for weight maintenance, children should be encouraged to undertake at least 60 minutes of moderate to vigorous physical activity over the course of each day (activity that makes them sweat and get out of breath).24 Adults should aim to undertake 2–3 hours of moderate intensity activity (fast walking or cycling) each week.25
While health benefits are maximised with higher levels of physical activity, the recommended target levels may seem unrealistic to some people and it is important to emphasise that even small and gradual increases in activity levels are worthwhile.21 Building sustainable habits is more likely if behaviours are incorporated into everyday routines. Thus, increasing regular walking, cycling, or other forms of active commuting (e.g. to school, work, or local destinations) may be more achievable than aiming for occasional bouts of activity in addition to daily routines.
It is also worthwhile exploring the time spent doing sedentary activities, such as TV watching or other screen-based activities, and discussing how this could be reduced. Examples include setting limits to daily screen activity or encouraging regular active breaks between sedentary periods.21
Encouraging healthy dietary habits
The evidence on individual dietary components and dietary patterns associated with weight gain is varied and sometimes conflicting; however, there are consistent messages that can be conveyed to patients. Generally, diets that are predominantly based on fruits, vegetables, beans and pulses, wholegrain foods, and fish (sometimes referred to as a Mediterranean diet) are less likely to be associated with excess weight gain.21 Nevertheless, over-consumption of any food type (including 'healthy' foods such as nuts or olive oil) can result in weight gain, and portion sizes should therefore be regulated.21
Consumption of energy dense foods and snacks (such as fried foods, confectionery, savoury snacks, and drinks made with full fat milk or cream) and high fat foods (including meat, milk and dairy products, fats and oils) should also be limited by reducing the frequency and amount consumed, considering alternatives (such as fruits, vegetables, or water), and choosing brands with lower fat and sugar content.21
In terms of drinks, there is good consistent evidence that drinking sugar-sweetened drinks (including sports drinks and carbonated drinks) leads to weight gain and should be avoided.15 Other high calorie drinks, such as those containing full fat milk or cream, as well as alcoholic drinks, should also be limited.21
Encouraging the development of health-promoting habits
A practical suggestion to address weight maintenance and prevention of excess weight gain is to encourage self-monitoring. Regular (e.g. weekly) self-weighing and using devices such as pedometers or apps that track physical activity, can serve as reminders and promote the development of healthy habits.21
How should messages be communicated?
Messages are more likely to be acted on if they are precise and simple, and communicated in a non-judgmental manner. Providing concrete examples that take into account the individual's particular circumstances are particularly likely to be appreciated. Box 2 (below) provides some examples of the types of concrete suggestions that could be given as appropriate. People are more likely to take notice if the message is framed to emphasise gains, focusing on the social (family bonding) and emotional (fun, happy occasions) benefits of maintaining a healthy weight.
Box 2: Examples of practical suggestions to promote weight maintenance and prevent weight gain21
- Swap unhealthy snacks for healthy alternatives such as fruits or vegetable sticks
- When choosing occasional energy dense snacks, opt for low fat, low sugar options and smaller portions
- Choose low fat options for milk and dairy products where possible
- Increase the high fibre or wholegrain components in your diet (e.g. opt for wholemeal bread and pasta, and include beans and pulses in your diet)
- Aim to eat a maximum of 70 g red and processed meats per day, by reducing portion size or the weekly frequency of consumption
- Check food and drink labels as a guide to appropriate portion sizes
- Drink water instead of drinks containing free sugars, particularly when being physically active
- Avoid compensatory overeating following physical activity
- Consider alternatives to 'sweet treats' as rewards or gifts, particularly for children
- Consider using the stairs instead of the lift
- Take regular active breaks from sitting at home or at work
- Take small gradual steps to change your diet and increase your physical activity levels.
Tailoring health messages
There is much evidence to suggest that people are more likely to engage with behavioural change if the message is tailored to consider the perceptions, habits, and life situation of each individual. For example, some people are more likely to be motivated if the physical and mental health benefits of weight maintenance are emphasised, while others may be motivated by shock statements.23
Many of the benefits of behavioural habits associated with weight maintenance have wide-ranging effects, and these should also be communicated, according to the individual's particular concerns. For example, improved fitness and better mood as a result of increased physical activity; and improved oral health and lower cholesterol levels resulting from a healthier diet, could be emphasised.21
The NICE guideline includes key messages based on the current best evidence, which can be communicated to all patients to help them prevent excess weight gain. Practical examples of how people can develop a healthier diet and increase levels of physical activity are derived either directly, or extrapolated from the evidence base. There is also guidance on how these messages can be communicated to encourage patients to adopt change. The challenge for primary care is to use all patient contacts as an opportunity to discuss lifestyle behaviour, and to introduce advice and guidance on weight maintenance within all consultations.
- Weight gain as we get older is common, but not inevitable
- Maintaining a healthy weight will reduce the risk of developing chronic disease and of premature mortality
- GPs should consider all patient visits as an opportunity to encourage maintenance of healthy weight and prevention of excess weight gain
- Patients should be encouraged to develop a combination of healthy eating and physical activity habits, making small gradual changes towards the recommended goals
- Incorporating change into regular routines is more likely to be successful than ad hoc activities, which are unlikely to be sustainable
- Advice should be given in simple, precise, and non-judgmental language, using practical examples
- Where possible, messages should be tailored to the individual's circumstances and perceptions, to increase the likelihood of behaviour change
- The wider benefits and gains of maintaining a healthy weight should be emphasised to encourage healthy behaviours.
GP commissioning messages
written by Dr David Jenner, NHS Alliance GMS contract/PBC Lead
- Rising levels of obesity are a major concern for commissioners as obesity can lead to an increase in incidence and morbidity from disease especially diabetes, cardiovascular disease, and cancers
- Since the Health and Social Care Act in England in 2013, responsibility for commissioning weight reduction and obesity prevention programmes has sat with Departments of Public Health in local authorities
- Health and Wellbeing Boards should, in their Joint Strategic Needs Assessments, identify the challenge of obesity and coordinate intervention to prevent and manage this problem through all agencies:
- this could include interventions in schools as well as specific targeted resources to primary care such as weight reduction programmes or even health facilitators attached to surgeries
- GPs and their surgery teams should be supported and incentivised by Departments of Public Health to identify those at risk and target effective interventions to them such as through the NHS Health Check programme.
- Health and Social Care Information Centre. Statistics on Obesity, Physical Activity and Diet—England 2015. HSCIC, 2015. Available at: www.hscic.gov.uk/catalogue/PUB16988/obes-phys-acti-diet-eng-2015.pdf (accessed 6 July 2015)
- Golubic R, Ekelund U, Wijndaele K, et al. Rate of weight gain predicts change in physical activity levels: a longitudinal analysis of the EPIC-Norfolk cohort. Int J Obes (Lond) 2013; 37 (3): 404–409.
- Peeters A, Magliano D, Backholer K, et al. Changes in the rates of weight and waist circumference gain in Australian adults over time: a longitudinal cohort study. BMJ open 2014; 4 (1).
- Health and Social Care Information Centre. National Child Measurement Programme: England, 2013/14 school year. HSCIC, 2014. Available at: www.hscic.gov.uk/catalogue/PUB16070/nati-chil-meas-prog-eng-2013-2014-rep.pdf
- National Obesity Observatory. Health risks of adult obesity. www.noo.org.uk/NOO_about_obesity/obesity_and_health/health_risk_adult (accessed 5 June 2015).
- Narayan K, Boyle J, Thompson T, et al. Effect of BMI on lifetime risk for diabetes in the US.Diabetes Care 2007; 30 (6); 1562–1566.
- Prospective Studies Collaboration. Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies. The Lancet 2009; 373: 1083–1096.
- Lobstein T, Baur L, Uauy R for the IASO International Obesity TaskForce. Obesity in children and young people: A crisis in public health. Obes Rev 2004; 5(Suppl 1): 04–85.
- Singh A, Mulder C, Twisk J et al. Tracking of childhood overweight into adulthood: a systematic review of the literature. Obes Rev 2008; 9 (5): 474–488.
- Baker J, Olsen L, Sørensen T. Childhood body-mass index and the risk of coronary heart disease in adulthood. New England Journal of Medicine 2007; 357 (23): 2329–2337.
- Must A, Jacques P, Dallal G, et al. Long-term morbidity and mortality of overweight adolescents. A follow-up of the Harvard Growth Study of 1922 to 1935. New England Journal of Medicine 1992; 327 (19): 1350–1355.
- Pulgaron E. Childhood obesity: a review of increased risk for physical and psychological comorbidities. Clin ther 2013; 35 (1): A18–32.
- Caird J, Kavanagh J, Oliver K, et al. (EPPICentre).Childhood obesity and educational attainment: A systematic review. London: EPPI Centre, 2011. Available at: eppi.ioe.ac.uk/cms/LinkClick.aspx?fileticket=9KvoPV_PSGY%3d&tabid=2954&mid=5535
- Hartmann-Boyce J, Johns D, Aveyard P et al.Managing overweight and obese adults: update review—the clinical effectiveness of long-term weight management schemes for adults (Review 1a). University of Oxford, 2013. Available at:www.nice.org.uk/guidance/ph53/evidence/ (accessed 6 July 2015).
- Morgan F, Weightman A, Whitehead S et al. Managing overweight and obesity among children and young people (PH47) Review 1: Effectiveness and cost effectiveness of lifestyle weight management services for children and young people. Cardiff University, 2013. Available at: www.nice.org.uk/proxy/?sourceUrl=http%3a%2f%2fwww.nice.org.uk%2f_gs%2flink%2f%3fid%3dDB3B8708-D04C-667A-E951EAEE0CAFF361
- Falconer C, Park M, Croker H, et al. The benefits and harms of providing parents with weight feedback as part of the national child measurement programme: a prospective cohort study. BMC Public Health 2014; 14: 549.
- Jolly K, Lewis A, Beach J et al. Comparison of range of commercial or primary care led weight reduction programmes with minimal intervention control for weight loss in obesity: lighten up randomised controlled trial. BMJ. 2011; 343: d6500.
- Saxena S, Francis N, Sharland M. Primary care of children: the unique role of GPs. The British Journal of General Practice 2012; 62 (600): 340–341.
- McAlpine D, Wilson A. Trends in obesityrelated counseling in primary care: 1995– 2004. Med Care 2007; 45 (4): 322–329. doi:10.1097/01.mlr.0000254575.19543.01
- Geense W, van de Glind I, Visscher T, et al. Barriers, facilitators and attitudes influencing health promotion activities in general practice: an explorative pilot study. BMC Fam Pract 2013, 14:20.
- NICE. Maintaining a healthy weight and preventing excess weight gain among adults and children. NICE Guideline 7. London: NICE, 2015. Available at: www.nice.org.uk/guidance/ng7
- Bazian Ltd, Johnson L, Sebire S. Maintaining a healthy weight and preventing excess weight gain in children and adults – partial update of CG43. Evidence review 1: An evidence review of modifiable diet and physical activity components, and associated behaviours. Centre for Public Health at NICE, 2014. Available at: www.nice.org.uk/guidance/ng7/evidence (accessed 6 July 2015).
- Bazian Ltd, Johnson L, Sebire S. Maintaining a healthy weight and preventing excess weight gain in children and adults – partial update of CG43. Evidence review 2: Qualitative evidence review of the most acceptable ways to communicate information about individually modifiable behaviours to help maintain a healthy weight or prevent excess weight gain. Centre for Public Health at NICE, 2014. Available at: www.nice.org.uk/guidance/ng7/evidence (accessed 6 July 2015).
- Strong W, Malina R, Blimkie C, et al. Evidence based physical activity for school-age youth.J Pediatr 2005; 146 (6): 732-737.
- Bull F, and the Expert Working Groups. Physical Activity Guidelines in the U.K.: Review and Recommendations. School of Sport, Exercise and Health Sciences, Loughborough University, 2010. Available at: www.gov. uk/government/uploads/system/uploads/attachment_data/file/213743/dh_128255.pdf (accessed 6 July 2015)