Jane Diggle and Dr Pam Brown offer 10 top tips on initiating conversations about weight and motivating people to make healthy changes
Many people believe that drugs are an easy route to weight loss. Orlistat is the only drug available on NHS prescription that is licensed for treatment of obesity. Treatment with orlistat should be discontinued after 12 weeks if patients have been unable to lose at least 5% of the body weight as measured at the start of therapy.17 Liraglutide 3 mg and other drugs have demonstrated efficacy but are not currently (February 2019) available on the NHS for treatment of obesity.18–22
8. Help people understand the benefits of physical activity
Physical inactivity and prolonged sitting are modifiable risk factors for mortality and morbidity.23 Being active improves cardiometabolic risk, so people without contraindications should be encouraged to aim for 150 minutes of moderate activity every week (or 75 minutes of vigorous activity), as well as strength exercise on at least 2 days per week.24
Help the patient to identify activities they enjoy, encourage walking, and discuss ways of building activity into daily life to help people become more active. Record activity level using a validated tool such as the General Practice Physical Activity Questionnaire.25 Refer to Exercise on Prescription and ‘Green Gym’ schemes to help motivated people to adopt active habits. Some practices partner with initiatives like Walking for health (www.walkingforhealth.org.uk) or parkrun (www.rcgp.org.uk/clinical-and-research/our-programmes/clinical-priorities/parkrun-practice.aspx) to provide additional options for ‘prescribing’ exercise.
Many people believe that inability to exercise (through lack of time or musculoskeletal problems) makes weight loss impossible. However, physical activity is less effective as a sole weight loss strategy than diet, although it can reduce visceral fat and insulin resistance,26–28 and in combination with diet only increases loss by around 1.5 kg compared with diet alone.29
9. Help people set realistic goals and support progress
People often have unrealistic weight loss goals and set themselves up for certain failure. Discussing realistic goals (including hidden health benefits) encourages people to feel successful and avoid disappointment and demotivation. Encourage SMART—Specific, Measurable, Achievable, Realistic, and Time‐sensitive—goals, which may be used to create meaningful action plans.
Regular weighing by healthcare professionals or in commercial programmes can support weight loss, so keep weighing scales and tape measures readily accessible. Recording weight and waist circumference helps track, and provide feedback on, progress. Slow, steady or rapid weight loss are both beneficial; speed of loss does not significantly influence weight regain as was previously believed.30
Achieving and maintaining weight loss of 3–5 kg (or 5% body weight) has significant health benefits, whereas attaining ideal weight or BMI is unrealistic for most. The recent DiRECT study demonstrated that losing 10–15 kg can result in remission of type 2 diabetes at 1 year.31
10. Signpost to help and support and know your local pathways
Healthcare professionals are often put off starting a conversation about weight due to lack of confidence in weight management, but most of the time the main role is in signposting people to other information, organisations, and resources. Commercial weight loss organisations may be more effective at helping people lose weight and maintain loss than practice teams.32 Check if you can refer patients at preferential rates to services in your local area.
Learn about your local obesity care pathway and Tier 2 and 3 services, so you can refer appropriate patients.
Discuss bariatric surgery with those who meet local criteria. The conversation should include the types of surgery and significant weight loss and health benefits. People often believe that they can continue to eat normally after surgery, and sharing the restrictions and potential side-effects often motivates re-engagement with medical management.
Sources of further information for healthcare professionals can be found in Box 1.
Specialist Practitioner Practice Nurse, South Kirkby, West Yorkshire
Dr Pam Brown
GP with special interest in diabetes, obesity, and lifestyle medicine,Swansea
Box 1: Sources of information about managing overweight and obesity in primary care
NICE Clinical Guideline (CG) 189 on Obesity: identification, assessment and management (www.nice.org.uk/cg189)
NICE Public health guideline (PH) 53 on Weight management: lifestyle services for overweight or obese adults (www.nice.org.uk/ph53)
Stop Obesity Alliance (stopobesityalliance.org)
Diabetes UK. Meal plans and diabetes. www.diabetes.org.uk/guide-to-diabetes/enjoy-food/eating-with-diabetes/meal-plans-
Diabetes UK. Evidence-based nutrition guidelines for the prevention and management of diabetes.www.diabetes.org.uk/professionals/position-statements-reports/food-nutrition-lifestyle/evidence-based-nutrition-guidelines-for-the-prevention-and-management-of-diabetes
- Butland B, Jebb S, Kopelman P et al; Foresight Programme. Tackling obesities: future choices—project report. London: Government Office for Science; 2007. assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/287937/07-1184x-tackling-obesities-future-choices-report.pdf
- Brown J, West R, Angus C. Comparison of brief interventions in primary care on smoking and excessive alcohol consumption: a population survey in England. Br J Gen Pract 2016; 66 (642): e1–e9.
- Stefan N, Harling H, Schulze M. Metabolically healthy obesity: the low hanging fruit in obesity treatment? Lancet Diabetes Endocrinol 2018; 6 (3): 249–258.
- STOP Obesity Alliance website. stopobesityalliance.org/ (accessed 11 February 2019).
- NICE. Obesity: identification, assessment and management. Clinical Guideline 189. NICE, 2014. www.nice.org.uk/cg189
- Royal College of Paediatrics and Child Health website. Body mass index (BMI) chart. www.rcpch.ac.uk/resources/body-mass-index-bmi-chart (accessed 11 February 2019).
- Adab P, Pallan M, Whincup P. Is BMI the best measure of obesity? BMJ 2018; 360: k1274.
- Nutall F. Body mass index. Obesity, BMI, and health: a critical review. Nutrition Research 2015; 3 (50): 117–128.
- NICE. BMI: preventing ill health and premature death in black, Asian and other minority ethnic groups. Public health guideline 46. NICE, 2013. www.nice.org.uk/ph46
- Scottish Intercollegiate Guidelines Network. Management of obesity. SIGN 115. Edinburgh: SIGN, 2010. Available at: www.sign.ac.uk/sign-115-management-of-obesity.html
- Ochner C, Tsai A, Kushner R, Wadden T. Treating obesity seriously: when recommendations for lifestyle change confront biological adaptations. Lancet Diabetes Endocrinol 2015; 3 (4): 232–234.
- Tobias D, Chen M, Manson J et al. Effect of low-fat diet interventions versus other diet interventions on long-term weight change in adults: a systematic review and meta-analysis. Lancet Diabetes Endocrinol 2015; 3 (12): 968–979.
- NICE. Weight management: lifestyle services for overweight or obese adults. Public health guideline 53. NICE, 2014. www.nice.org.uk/ph53
- Ma C, Avenell A, Bolland M et al. Effects of weight loss interventions for adults who are obese on mortality, cardiovascular disease and cancer: systematic review and meta-analysis. BMJ 2017; 359: j4849.
- NHS England, Personalised Care Group, Patient Activation. Module 1: Patient Activation Measure—implementation—quick guide. NHSE, 2018. Available at: www.england.nhs.uk/publication/module-1-patient-activation-measure-implementation-quick-guide/ (accessed 11 February 2019).
- Prochaska J, DiClemente C. Trans-theoretical therapy—toward a more integrative model of change. Psychotherapy: Theory, Research & Practice 1982; 19 (3): 276–288.
- Amneal Pharma Europe Limited. Orlistat 120 mg hard capsules—summary of product characteristics. June 2016. www.medicines.org.uk/emc/product/8703/smpc
- Mehta A, Marso S, Neeland I. Liraglutide for weight management: a critical review of the evidence. Obes Sci Pract 2017; 3 (1): 3–14. doi: 10.1002/osp4.84.
- NICE. Liraglutide for managing overweight and obesity [ID740]. Proposed [GID-TA10388]. www.nice.org.uk/guidance/proposed/gid-ta10388
- Greenway F, Fujioka K, Plodkowski R et al. Effect of naltrexone plus bupropion on weight loss in overweight and obese adults (COR-I): a multicentre, randomised, doubleblind, placebo-controlled, phase 3 trial. Lancet 2010; 376 (9741): 595–605.
- NICE. Naltrexone–bupropion for managing overweight and obesity. Technology appraisal guidance 494. NICE, 2017. www.nice.org.uk/ta494
- Smith S, Weissman N, Anderson C. Multicenter, placebo-controlled trial of lorcaserin for weight management. N Engl J Med 2010; 363 (3): 245–256.
- Lee I, Shiroma E, Lobelo F et al. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet 2012; 380 (9838): 219–229.
- NHS website. Live well—exercise. Physical activity guidelines for adults. www.nhs.uk/live-well/exercise/ (accessed 1 February 2019).
- Department of Health and Social Care. General practice physical activity questionnaire (GPPAQ). DHSC, 2013. Available at: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/192450/GPPAQ_-_pdf_version.pdf
- Thorogood A, Mottillo S, Shimony A et al. Isolated aerobic exercise and weight loss: a systematic review and meta-analysis of randomized controlled trials. Am J Med 2011; 124 (8): 747–755.
- Shaw K, Gennat H, O’Rourke P, Del Mar C. Exercise for overweight or obesity. Cochrane Database Syst Rev 2006; (4): CD003817.
- Di Meo S, Iossa S, Venditti P. Improvement of obesity-linked skeletal muscle insulin resistance by strength and endurance training. J Endocrinol 2017; 234 (3): R159–R181.
- Catenacci V, Wyatt H. The role of physical activity in producing and maintaining weight loss. Nat Clin Pract Endocrinol Metab 2007; 3 (7): 518–529.
- Nackers L, Ross K, Perri M. The association between rate of initial weight loss and long-term success in obesity treatment: does slow and steady win the race? Int J Behav Med 2010; 17 (3): 161–167.
- Lean M, Leslie W, Barnes A et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. Lancet 2018; 391: 541–551.
- Ahern A, Wheeler G, Aveyard P et al. Extended and standard duration weight-loss programme referrals for adults in primary care (WRAP): a randomised controlled trial. Lancet 2017; 389 (10085): 2214–2225.