Obesity is a condition that GPs encounter in practice on a daily basis. Obesity rates have risen in recent years such that in 1998, 17 of 100 adult males and 21 of 100 adult females in England were obese.1
Management of obesity has traditionally focused on dietary advice, very low calorie diets, behavioural modification, counselling and exercise, often provided by specialist clinics. Yet most patients tend to regain any weight they manage to lose.
We now have drugs available that have been shown to help patients achieve, and more importantly maintain, clinically relevant degrees of weight loss. Having earlier approved the use of the intestinal lipase inhibitor orlistat, the National Institute for Clinical Excellence (NICE) has recently provided guidance on the use of the serotonin and noradrenaline reuptake inhibiting agent sibutramine.2
Sibutramine is indicated for people aged 18-65 years who have a BMI >=30kg/m2, or a BMI >=27kg/m2 with other significant diseases (e.g. type 2 diabetes, hypertension and/or hypercholesterolaemia).
NICE recommends that sibutramine be given at 10mg/day, with therapy continued beyond 4 weeks only if patients have lost 2kg weight. Treatment should then only be continued beyond 3 months if patients have lost at least 5% of their initial body weight.
While NICE guidance is welcome, implementing its recommendations presents a substantial challenge to GPs. Simply writing a prescription for sibutramine, even for an appropriately selected patient, is not enough, as NICE recognises. Use of the drug must be monitored to ensure that the patient is responding in terms of weight loss and to ensure there are no side-effects that may warrant discontinuation of the drug, such as a rise in blood pressure or heart rate.
But the concerns are not purely medical. Most obese and overweight patients will have made many previous attempts to lose weight, whether formally or informally; many will have seen or heard media reports and think that sibutramine is the answer to their problems. Yet many will be disappointed by the potentially limited amount of weight loss they are able to achieve with it, which may dissuade them from complying with dietary and exercise measures.
We need to help patients understand that, taken appropriately, sibutramine can help them lose 5-10% of their initial body weight, and will result in beneficial health effects.
NICE acknowledges that those prescribed sibutramine should also be offered advice, support and counselling on diet, exercise and behaviour changes through an integrated weight management programme.
Given the likely number of patients and the extensive ongoing care needed, traditional one-to-one care by a GP will inevitably be difficult to provide. Following initial assessment, patients prescribed sibutramine should have access to as many members of the primary care team as possible for supervision, counselling, dietary advice and motivation.
Some members of the team may need specialist training, e.g. those advising patients need to be able to distinguish between the weight loss and weight management phases of management with sibutramine and to adopt appropriate strategies for each.
Most practices will find that this kind of multidisciplinary service is best provided in weight management clinics, or in open sessions in which patients can derive support and encouragement from each other while still accessing appropriate medical care. Consideration must be given as to whether services should be provided at a practice level or across the primary care organisation.
- See also 'NICE issues guidance on sibutramine' in this issue.
- National Audit Office. Tackling Obesity in England: Report by the Comptroller and Auditor General. London: The Stationery Office, 2001.
- NICE. Guidance on the Use of Sibutramine for the Treatment of Obesity in Adults. Technology Appraisal Guidance No 31, October 2001.