In the past few years, the treatment of obesity has become increasingly recognised as a priority for improving health, yet primary care guidelines did not exist and the prevalence of obesity continued to rise.
Obesity is predominantly a primary care problem, and practical management guidelines are part of the solution. The National Obesity Forum (NOF), a group of primary healthcare professionals dedicated to improving the management of obesity and overweight, has recently developed specific primary care guidelines (see Figure 1, below).
|Figure 1: NOF guidelines on management of obesity|
The NOF recognised that there was an urgent need for a concise summary combining evidence from numerous academic and secondary care documents, balanced with the realities of primary care.
The resulting guidance is designed to simplify the management of obesity and overweight in primary care.
The NOF summary encompasses recommendations from such reputable sources as the Royal College of Physicians (RCP),1 the Scottish Intercollegiate Guidelines Network (SIGN)2 and the World Health Organization3 (see Table 1, below).
Table 1: World Health Organization Classification of obesity and its risk to health
|Category||Body mass index||Health status|
|Obese Class I||30–34.9||Increased|
|Obese Class II||35–39.9||Greatly increased|
|Obese Class III||>40||Substantially increased|
More than 20% of the UK population are obese, and obesity is a condition that requires long-term management: the scale of the problem is thus too great for secondary care services to manage alone.
Primary care involvement has sometimes been lukewarm and inconsistent. The management of obesity is often viewed as a lesser priority in general practice, and the prevalence of obesity and overweight has grown.
Health professionals need to appraise their treatment methods and prejudices that may interfere with the management of obesity.
Primary care trusts and groups also need to create a climate within which obesity can be treated more enthusiastically.
Why manage obesity?
One in two of the UK population are currently overweight, and numbers are increasing rapidly.4 The rising challenge of obesity needs to be addressed with urgency before it becomes even more widespread.
A recently published report from the National Audit Office has estimated that the treatment of obesity and its consequences cost the NHS at least £0.5 billion a year. 5
Obesity is associated with serious co-morbidities including:
- Type 2 diabetes
- Cardiovascular disease
- Mental health problems.
The management and prevention of these diseases often lie within }rimary care, and prevention through weight management can help ease patient suffering and may help achieve health targets.
For instance, obese people are twice as likely to die from cardiovascular disease compared with people of a healthy weight.6
The National Service Framework for Coronary Heart Disease aims to reduce the death rate in people under 75 years of age by at least two-fifths by 2010.7
Weight loss helps to achieve a drop in cholesterol level, reducing a patient's chance of dying from cardiovascular disease.8 By helping patients achieve a 5–10% weight loss and the health benefits associated with it, primary care may improve the likelihood of achieving government health targets.
Obesity is also related to mental health. Obese women are 37% more likely to be diagnosed with major depression and 23% more likely to attempt suicide.9
The National Service Framework for Mental Health aims to reduce the death rate from suicide and undetermined injury by at least a fifth. Iddressing obesity can play a role in long-term mental health management.
Causes of obesity
Overweight and obesity can be caused by a variety of factors, but they share a simple common link – energy intake exceeds energy output.
Initial investigations may indicate that the patient has a more serious metabolic problem, but in many cases appropriate advice and support will help the patient to succeed (see Table 2, below).
Table 2: Causes of obesity
|Decreased physical activity||E.g. watching too much television|
|Increased calorie and fat intake||Especially associated with change of diet, e.g. American Indians, and former Eastern bloc citizens who have a higher-fat diet than previously, thanks to modern American eating habits. Bottle-fed babies have a higher risk of future obesity|
|Environmental||Obesity is more prevalent in lower classes. Lifestyle is an important factor; obesity may run in families without there being a genetic cause|
|Genetic||Twin studies have proved a genetic link; around 200 genes are currently being studied. This is related to low metabolic rate and energy efficiency|
|Psychological||Disturbance of self-image, including some eating disorders, e.g. bulimia; depression|
|Endocrine||Corticosteroid excess, hypothyroidism, pathology or damage to the hypothalamus, pituitary disease, polycystic ovaries|
|Developmental||Hypertrophic obesity (increased size of fat cells, usual in adult-onset obesity); hyperplastic obesity (increased number of fat cells, usual in juvenile-onset obesity), although they are now thought to coexist; age|
|Inherited||Laurence-Moon-Biedl syndrome, Prader-Willi syndrome, etc|
Implementing the guidelines
The NOF guidelines are in line with those produced by the RCP and SIGN, which recommend behaviour modification as first line.
Managing a patient's expectations for weight loss is very important, both to help motivate the patient and to achieve overall health benefits.
First-line treatment includes increased physical activity and a reduced calorie diet, particularly limiting dietary fat.
After 3–6 months, if the patient has not achieved his/her goals (e.g. 5–10% weight reduction, improvements in symptoms or reduced markers of co-morbidity), second-line treatment should be considered. This includes:
- Behavioural therapy
- Alternative treatments
- Referral to secondary care.
The only drug treatment currently available in the UK is orlistat, which works by reducing absorption of fat in the gastrointestinal tract. In conjunction with a reduced fat diet, it may help to achieve a more rapid and greater weight loss.
Sibutramine has recently gained European approval and may be licensed in the UK during 2001.
The NOF guidelines highlight the need for health professionals to be proactive in their patient selection methods. GPs can help instill confidence and determination in a patient who may have previously tried to lose weight.
Increasingly, patients are becoming aware that their weight has an impact on their health. However, they are not always able to put this knowledge into practice and need to be prompted by their GP to take action.
Once a patient has had his/ her initial consultation, a multidisciplinary approach is very important to long-term weight loss and maintenance.
Support from nurses and dietitians is the key to success. If patients do not initially achieve their goals, it is important to remain positive and encourage them by highlighting the fact that weight requires long-term management.
In addition to producing the guidelines, the NOF seeks to inform all primary care workers of the extent and seriousness of obesity by creating opportunities for educational training and identifying practical steps toward integrated obesity management throughout the UK.
The NOF will shortly be announcing an award for excellence for the treatment of obesity in primary care.
- The guidelines are posted on the NOF website at www.nationalobesityforum.org.uk. Membership is free of charge and open to all health professionals working within primary care. To join please write to: National Obesity Forum, PO Box 6625, Nottingham NG2 5PA (Tel: 0115 8462109).
- Clinical Management of Overweight and Obese Patients. London: Royal College of Physicians, 1998.
- Scottish Intercollegiate Guidelines Network. Obesity in Scotland. Integrating Prevention with Weight Management. A national clinical guideline recommended for use in Scotland. Edinburgh: SIGN, 1996.
- World Health Organization. Obesity: Preventing and Managing the Global Epidemic. Geneva: WHO, 1997.
- Department of Health. Health Survey for England. Adult Reference Tables 1997.
- National Audit Office. Tackling Obesity in England. Executive Summary. London: The Stationery Office, 2001.
- Calle E, Thun MJ, Petrelli, JM, Rodriguez C, Heath CW. Body-mass index and mortality in prospective cohort of US adults. N Engl J Med 1999; 341: 1097-105.
- Department of Health. Saving Lives: Our Healthier Nation. CM4386. London: The Stationery Office, 1999.
- Wadden TA, Anderson DA, Foster GD. Two-year changes in lipids and lipoproteins associated with the maintenance of a 5% to 10% reduction in initial weight: some findings and some questions. Obes Res. 1999; 7: 170-8.
- Carpenter KM, Hasin DS, Allison DB, Faith MS. Relationships between obesity and DSM-IV Major Depressive Disorder, Suicide Ideation, and Suicide Attempts: results from a general population study. Am J Public Health 2000; 90(2); 251-7.
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