Dr David Haslam argues that crucial training and resources are needed, not more evidence as provided by the NICE obesity guidance

The national obesity crisis, represented by the inexorable rise in the prevalence of this condition, has been impervious to any initiative or intervention that has been developed. There is a limited, possibly 10-year, window of opportunity in which to act before the UK ends up in the same parlous state of health with regard to overweight as the USA.

Recognising the problem

The UK Government recognises the seriousness of the situation, and has prioritised tackling obesity in a series of reports and documents dating back to 1990. However, its track record is poor; The Health of the Nation report, published in 1990, which was based on figures published in 1985, stated that an acceptable 20-year target for 2005 would be obesity rates of 6% for men and 8% for women1—targets that were missed by around 400% based on BMI measurements.1

Over the past 6 years, there has been an immense amount of discussion on the subject of obesity, its causes, consequences, and possible treatments. Some imaginative ideas have been expressed, and important projects have been presented.3–6 However, the frontline action has been left to the likes of Jamie Oliver and a select group of passionate individuals.

What is not needed is another round of discussions, but the recently published NICE guideline on the management of obesity follows a depressingly similar pattern.7 It appears to be an intensive, laborious attempt to create the mirage that the Government is acting against the obesity crisis, whereas the end-result is disappointingly lacking.

Who will use the guideline?

The foreword to the guideline states: 'Our recommendations have been formulated with different audiences in mind: public, professionals and those in responsible positions in the health services, local government, education, partnership organisations, the workplace and the voluntary sector.'8

However, Mayur Lakhani, Chairman of the Royal College of General Practitioners, is far more specific in his preface: 'As a practising GP, I know that primary care has a crucial role to play in the assessment and management of adults with obesity. In order for primary care health workers to take on this role they need to know what works, and require better training and resourcing of management programmes that incorporate dietary advice, physical activity and behavioural change. This clinical guideline offers general practitioners, practice nurses, community dietitians and others a systematic review of the evidence of weight loss interventions, with clear summaries of their effectiveness.' 8

Mayur Lakhani's two statements do not sit well together; the guidance does not provide primary healthcare professionals with crucial training and resources, it merely provides the evidence, of which we are already aware. Although it does acknowledge that staff will need to be trained and that dedicated resources should be allocated.

It is not surprising that the guideline is unhelpful for GPs, as there was minimal input from them in the development of the guideline. Of more practical use to them would have been the allocation of resources to primary care to tackle obesity, as well as to empower GPs to take positive steps to improve the situation. Without the offer of further help, it is hard to substantiate the avowed claims that the guideline will assist GPs.

The final document is so big and wide-ranging that, in its attempt to be all things to all people, Dr Lakhani's wish remains unfulfilled, and I feel that the primary care team is no better off for its production.

The beneficiaries of the guidance will, instead, be those in the Government, local government, and the health services, who now have a substantial, influential tome that can be used to provide compelling background evidence to help get services set up, and overcome some of the bureaucracy that obstructs the adequate provision of weight management.

Is a guideline on obesity needed?

Whether or not the guideline is necessary depends on your point of view. Healthcare professionals know how to treat obesity in an individual, but we struggle to replicate our success at a population level.

What we most definitely do not need is a document that represents a minute trawl through the evidence on obesity. What would be of help to GPs is encouragement to make effective use of the skills we already possess.

There are several ways in which this could have been achieved:

  • the expansion of the obesity indicators in the GMS contract—to include screening for and primary prevention of cardiometabolic disease, as well as steps to counteract childhood obesity—would make an immediate difference to the long-term management of the condition
  • if the UK National Screening Committee was to recommend the screening of obese individuals for cardiometabolic risk factors—this is soon to be reviewed
  • by effective assessment of childhood obesity in schools, without the option of parental opt-out
  • by the genuine provision of resources to PCTs, a measure that would provide huge medium- and long-term financial savings.

The guidance may prove to be useful as an influential body of evidence to persuade reluctant PCTs when decisions about provision of services are being made. However, it is unclear if it will provide the primary care sector with any other help than this.

Does the guideline achieve its aims?

Only time will tell whether or not the NICE obesity guideline fulfils its objectives. It is a useful compendium of knowledge, but it is certainly not comprehensive; for example, there is nothing concerning children under 2 years of age, despite breast-feeding, weaning, and first foods being crucial stages with respect to obesity. Also, meal replacements are ignored despite excellent long-term evidence.9,10

Furthermore, the guideline actually contains some inaccuracies; very low calorie diets are categorised by the European Commission as below 800 kilocalories,11 but NICE classifies these as being below 1000 kilocalories.

In addition, the guideline states categorically that there are two available anti-obesity drugs, orlistat and sibutramine, although with the launch of rimonabant there are actually three drugs available in the UK at present.

Rightly or wrongly the NICE guideline has placed enormous emphasis on the use of surgery and pharmacotherapy in children, despite the paucity of evidence. Although such severe measures have an important role in desperate situations, the media has sensationalised them, which has detracted from the more important aspects of the guidance.

Summary

Despite the claim that the NICE obesity guideline is aimed at GPs in a clinical setting, I feel that its real use is as an influential tool for the Government and service providers to use as ammunition in their endeavour to improve obesity services. On balance, however successful the guideline turns out to be in this respect, it is still just more discussion, when decisive action is what is actually required.

  1. Department of Health. The Health of the Nation: a strategy for health in England. London: HMSO, 1990.
  2. Department of Health. Health survey for England 2004. Updating of trend tables to include 2004 data. London: Department of Health, 2005.
  3. Wanless D and HM Treasury. Securing good health for the whole population: Final report—February 2004. London: HMSO, 2004.
  4. Department of Health. Choosing Health: Making healthy choices easier. London: HMSO, 2004.
  5. Health Select Committee. Health Select Committee Report on Obesity—27 May 2004. London: HMSO, 2004.
  6. National Audit Office. Tackling Obesity in England. London; NAO, 2001.
  7. National Institute for Health and Care Excellence. Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. Clinical Guideline No 43. London: NICE, 2006.
  8. National Institute for Health and Care Excellence and National Collaborating Centre for Primary Care. Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. Clinical Guideline No 43. London: NICE, 2006.
  9. Flechtner-Mors M, Ditschuneit H, Johnson T. Metabolic and weight loss effects of long-term dietary intervention in obese patients: four-year results. Obes Res 2000; 8 (5): 399–402.
  10. Ditschuneit H, Flechtner-Mors M, Johnson T, Adler G. Metabolic and weight-loss effects of a long-term dietary intervention in obese patients. Am J Clin Nutr 1999; 69 (2): 198–204.
  11. http://europa.eu/index_en.htmG