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Managing obesity in primary care

Carol Ottley
BSc SRD RPHNutr
Public Health Nutrition Consultant

Excessive weight is associated with considerable health costs, and the government has recognised that something needs to be done. So how can primary healthcare professionals help in the management of the problem?

Why treat obesity?
Apart from the psychological costs of owning an unfashionable body shape, obesity is associated with considerable physical ill-health. Obese people have an increased risk of a number of serious diseases and ­distressing conditions, such as:

  • Coronary heart disease and stroke.
  • Type 2 diabetes.
  • Certain cancers (such as breast and colon cancer).
  • Gynaecological abnormalities.
  • Osteoarthritis, gout and other problems in weight-bearing joints.
  • Gallstones.
  • Stress incontinence.
  • Breathing difficulties and sleep apnoea.

The National Audit Office estimate that obesity accounted for 18 million days of sickness leave in the UK in 1998.(3) A detailed analysis of available data on weight loss has found that even moderate weight loss in those who are seriously overweight or obese substantially reduces risk factors for diabetes and heart disease.(4) This includes reductions in blood pressure, blood triglycerides, blood glucose and low-density lipoprotein (LDL) cholesterol (which increases the risk of heart disease). In addition, an increase in high-density lipoprotein (HDL) cholesterol (which reduces the risk of heart disease) can also occur as a result of moderate weight loss. A gradual weight loss of one to two pounds per week in the obese, and a half a pound to a pound per week in the overweight, is enough to make a big difference in terms of health.

Guidelines
The primary care setting is an ideal place to help people control their weight, and guidelines have been published to provide a framework for treating the disease.(4-6) Most recently in the UK, the National Obesity Forum has produced guidelines for the management of adult obesity and overweight people in primary care,(6) which give advice on the selection of patients, teamwork and treatment options. These guidelines can help in the preparation of a local strategy.

Who to treat?
The primary decision is who should be targeted for treatment. Defining who is obese or at particular risk of associated diseases is the first step. For adults the body mass index or BMI is used, which is calculated by dividing weight (in kilograms) by height (metres squared). The BMI cutoff points used to classify weight status are shown in Table 1.

[[NIP06_table1_61]]

The BMI does not take into account the distribution of fat around the body, and it is now generally accepted that people who deposit their excess fat in the abdominal area are more likely to suffer the negative health consequences of obesity, compared with those whose extra fat is found on the hips and thighs. A simple waist measurement has been found to correlate well with BMI and is an accurate and practical assessment of abdominal obesity. Table 2 shows the waist measurements that indicate an increased risk of obesity complications.(5)

[[NIP06_table2_61]]

Apart from height, weight and waist circumference measurements, other tests such as blood pressure, blood sugar, blood lipids or urinalysis may be necessary to determine any comorbidities. The National Obesity Forum suggests that patients with a BMI over 30, or any overweight patient with coinciding diabetes or other serious disease, should be targeted, as should patients who self-refer where appropriate.(6)

Multidisciplinary approach
A review of the data on weight loss found that there was no magic formula for weight loss. Different approaches were successful in different circumstances and with different types of people.(7) However, there is now considerable support for the concept of a multidisciplinary approach. This approach includes behaviour modification, dietary advice and physical activity, and all of these components have to be tailored to the individual's needs.(4)

Motivation and encouragement
A patient must be motivated to lose weight in the first place, otherwise all the time and effort invested will come to nothing. The decision to lose weight must be made jointly between the health professional and patient. It is important that realistic targets are agreed, perhaps only a pound or two a week for six months. For many individuals this will still leave them overweight, but that is better than aiming to reach ideal body weight and never getting there. Moderate weight loss has substantial health benefits, and achieving a realistic goal helps boost self-esteem.

Behaviour modification
This should be carried out under the guidance of a behavioural therapist or other suitably qualified practitioner. The individual is given tools to help overcome barriers that prevent them from complying with dietary changes and increasing physical activity. Specific strategies include: self-monitoring of eating habits and physical activity; stress management; stimulus control; problem solving; contingency management; and social support. It is also important to reinforce to patients that long-term changes in lifestyle are needed to achieve long-term weight loss.

Dietary therapy
Dietary modification is the cornerstone of weight loss, and a reduction in the quantity of calories by about 500-600 per day will lead to the desired rate of weight loss. Very overweight or obese men and women will lose weight on 2,000 and 1,500 calories respectively due to their initial high calorie needs. For moderately overweight men and women, about 1,500 and 1,000 calories per day respectively are appropriate. Very low calorie intakes should be avoided as they can lead to diet-breaking binges and health complications.
Changes in the quality of the diet are also important. Fat is a calorie-dense nutrient, so a reduction in fat, especially saturated fat, is a useful way of cutting calories without cutting down on bulk. All carbohydrates should be encouraged as they help to reduce hunger, making it easier to stick to the diet. Carbohydrate sources include:

  • All types of bread, rice, noodles, pasta and ­potatoes.
  • All types of breakfast cereals.
  • Fresh, dried and canned fruit.
  • Peas, beans, lentils and chickpeas.
  • Sugar, honey and preserves.
  • Fruit juices and regular soft drinks.

A major European study has shown that free-living, slightly overweight people who ate whatever they wanted from a special range of low-fat, high carbohydrate foods lost weight even though they were not consciously restricting calories.(8)
It is also a good idea to build favourite foods into the diet as this makes it easier to stick to, especially in the long term. A recent study examined the impact of including sugar- containing foods within a low-fat slimming diet.(9) It was found that weight loss was similar to a more conventional low-sugar, low-fat diet, and the authors concluded that there is no rationale for cutting out sugar when slimming.

Physical activity
Being more active should also be a key component in a weight loss programme. Although it is does not seem to lead to substantially greater weight loss initially, it helps people keep the weight off in the long term. Activity also helps reduce cardiovascular and diabetes risk to a greater extent than weight loss alone.
As with dietary advice, the type of physical activity suggested must be tailored to the individual. For the very obese, even gentle walking may be exhausting, so spending less time sitting down could be a first step. Everyone is different in their level of fitness and preferred activities, so it is vital that people choose something they really enjoy and can manage comfortably.
Being more active does not necessarily have to take the form of a sport - it could be a hobby which gets someone out and about instead of watching TV, an active interest such as gardening, or simply taking the more energetic option, for example using the stairs instead of the lift. Every little bit of activity counts, helping to improve health and fitness and increase calorie requirements.

Long-term commitment
Analysis of weight loss programmes shows that losing the weight is relatively easy compared with keeping the weight off in the long term. Studies show that after six months most slimmers gradually start to regain weight.(7) There is now strong evidence that weight loss is maintained more successfully if some form of therapy is continued in the long term. Observation, monitoring and motivation by appropriate health professionals is recommended for up to three years.(4)

Teamwork
The primary care team are ideally placed to help people lose weight. Guidelines are now available to help in the preparation of a local strategy for tackling the problem. Nurses, dietitians, doctors and other healthcare professionals may all be involved, and it is vital that everyone provides consistent advice. Combining motivation and sensible advice on diet and lifestyle with supervision and support is an approach that is likely to succeed.

[[NIP06_pp_64]]

References

  1. World Health Organization. Obesity - preventing and managing the global epidemic. Report of the WHO consultation on obesity. Geneva: WHO; 1997.
  2. Department of Health. Health survey for England 1996. London: HMSO; 1998.
  3. National Audit Office. Tackling obesity in England. London: NAO; 2001.
  4. National Heart, Lung and Blood Institute for Health USA. Clinical guidelines on the identification, ­evaluation and treatment of overweight and obesity in adults. J Am Diet Assoc 1998;98:1178-91.
  5. Scottish Intercollegiate Guidelines Network. Obesity in Scotland. Integrating prevention with weight management. A national clinical guideline recommended for use in Scotland. Edinburgh: SIGN; 1996.
  6. National Obesity Forum. Guidelines on management of adult obesity and overweight in primary care. Available from URL: http://www.nationalobesityforum.org.uk/guidelines
  7. Glenny AM, O'Meara S, Melville A, Sheldon TA, Wilson C. Treatment and prevention of obesity: a systematic review of the literature. Int J Obes Relat Metab Disord 1997;21;715-37.
  8. Saris WH, Astrup A, Prentice AM, et al. Randomized controlled trial of changes in dietary carbohydrate/fat ratio and simple vs complex carbohydrates on body weight and blood lipids. Int J Obes Relat Metab Disord 2000;24:1310-18.
  9. West JA, de Looy AE. Weight loss in overweight subjects following low-sucrose or sucrose-containing diets. Int J Obes Relat Metab Disord 2001;25:1122-8.

Resources
The Sugar Bureau
Duncan House Dolphin Square
London SW1V 3PW
W:www.sugar-bureau.co.uk
National Obesity Forum
W:www.nationalobesityforum.org.uk
British Nutrition Foundation
High Holborn House
52-54 High Holborn
London WC1V 6RQ
W:www.nutrition.org.uk