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National Obesity Forum conference report

Alison Wall
BSc
Health Visitor/ Public Health Nurse/Child Protection Lead
Watford and Three Rivers PCT

The World Health Organization (WHO) defines an epidemic as a disease state affecting 15% of the population.(1) Obesity rates are 23% for men and 23.5% for women in the UK, and with present trends the inexorable rise shows no sign of turning around.(2) Obesity is linked with over 45 comorbidities, some of which are the biggest killers, such as heart disease, stroke and type 2 diabetes. This leaves society with a profound dilemma.

Causes of obesity
Causes are certainly complex. On the one hand there are the internal factors, such as genetic make-up, hormonal influence on satiety level and calorie intake. The genetic contribution is significant, as research has found a high concordance rate for twins.
Then there are the external influences from our environment. Sedentary lifestyles result in the burning of fewer calories, and therefore more weight is gained.
There is also the increasing availability of energy-dense foods. Some medications may predispose to weight gain, such as some antidepressants and corticosteroids.(3)

Measuring overweight and obesity
BMI index is the most commonly used tool to measure obesity. Disease risk can increase at relatively modest BMI readings, so it is necessary to measure both those who are just overweight, as well as those with more extreme indices. Age should also be considered, as some diseases are linked to specific age categories: for example, cardiovascular risk is more directly linked to those aged 30-40 years. Racial differences are apparent too - for instance, Asians are at greater risk of metabolic syndrome than Caucasians. This is explained by the fact that ethnicity affects the deposition sites of body fat.
However, the conference felt that BMI may not be the best measure, as it is hard to distinguish between fat and muscle mass in the calculations.
Children should be measured with child-specific charts that are available from the Child Growth Foundation. McCarthy et al highlight the fact that there are clear gender differences for body fat centiles.(4)
Waist circumference is a helpful measure, but there are problems with reproducibility. This may be resolved by employing the same clinician to carry out the measurements and being specific about the site used to measure. Generally, the obese have a large waist, and the lean have small waists. However, there can be discrepancies, particularly between a BMI of 25 and 30, so it can be really helpful to measure both in this range.
Measuring skinfold thickness seems to be going out of fashion, and is invasive with poor reproducibility.
New bioelectrical impedance machines are now available, which are simple, accurate and easily reproducible. Costs vary between £300 and £2,000, so a PCT may consider it worth sharing across the organisation.

What strategies work?
Research evidence has shown unequivocally that modest weight reduction will result in significant health gains.(2) Therefore modest weight reduction is the aim of strategies in obesity management.
Infertility is linked with obesity, and it could be argued that the focus of care should be on weight loss, rather than divesting expensive resources on infertility treatments.
Activity that is incorporated into a person's lifestyle is more likely to be successful and sustained than an "add-on" activity schedule. Small changes are more likely to work than big ones. Extended support is also important to help maintain weight maintenance, so it is critical that support is not just offered for a short period and then stopped.

Online diets
A number of sites offer support online, both free and fee paying. Some of these are listed in the resource section and may be the preferred first-line strategy.

Pharmacotherapy
Pharmacotherapy plays an important part in the overall management of weight. In the past, a huge array of pills and potions were marketed for weight loss, without the rigours imposed on the industry today. People still recall the use of barbiturates and amphetamines for weight loss, and this may well taint their perception of the benefits of medications today. This needs to be considered when choosing an appropriate strategy and should not cloud our judgement.
Currently, there are three main drugs used in obesity control, which work through different pathways:

  • Orlistat (Xenical; Roche) has been studied over a four-year period and shows significant benefits. A new licence has been issued for adolescents. Diet is an integral part of therapy. It is a lipase inhibitor - in other words, it decreases fat absorption.
  • Sibutramine (Reductil; Abbott) is a serotonin-receptor reuptake inhibitor and acts centrally. It has been audited over a two-year cycle and works by making the patient feel full quickly.
  • Rimonabant (Acomplia; Sanofi Aventis) is a cannabinoid that is used once daily before breakfast. It modulates the effect of primary neurotransmitters and is used as an adjunct to diet and exercise. It improves glycaemic control and causes a reduction in triglycerides.

These drugs should not be used in combination as interaction studies have not been completed, so the consequences of combined use are not known. Generally these drugs need to be avoided in certain conditions, such as depression and psychoses.
Conference heard about future drugs that will be available, some of which appear to be more effective and powerful than the present options.
However, they will be evaluated by the National Institute for Health and Clinical Excellence (NICE), to decide whether they are a cost-benefit alternative. Meal replacements, such as Slimfast and the Cambridge diet, have good evidence to demonstrate that they are cost-effective, where lifestyle changes have failed in the care pathway.(5)
Surgery is an option when other strategies have failed or are not appropriate. There are various techniques available, but all carry risks, particularly if the person is grossly obese. The Swedish Obese Study (SOS) showed that bypass surgery was more effective than banding the abdomen.(6) Primary care trusts are not commissioning this work at present, but this should possibly be re-evaluated.(7)

Behaviour change
People need to make the changes for themselves, but what is behaviour change, and how can it be encouraged?
It is an agreed fact that if you tell someone to do a certain thing, or if you use scare tactics, the person is less likely to do it. Interpersonal skills are vitally important. The practitioner needs to get alongside the individual and listen and reflect on their concerns. Raising the issue and talking about weight is difficult as it is so sensitive a subject that goes right to the core of self-esteem.
A collaborative arrangement should be made with the client, rather than imposing our own strategies. We need to be empathic and nonjudgemental to help the client discuss how they feel and what actions they would like to explore.
The Department of Health is developing a social marketing tool to use for obesity prevention. The programme lead has moved into the department from the commercial sector, and so brings experience of marketing strategy to the table. The process so far has involved exploration of the issues, research and stakeholder input. This has been assisted by an Expert Review Group, which has monitored developments and helped refine the work into a strategy. The intention is to roll out the programme early in 2007.

Strategy into action
With the completion of a health strategy, we must not assume that obesity services will be commissioned.
Regional networks are really essential to assist local implementation and to maintain motivation. Practice can be shared across the network and allow integration of existing work. Networks provide economies of scale and facilitate the drawing up of appropriate services.
In the commissioning framework, an inclusive approach is preferred. NHS, private and voluntary organisations are setting up support programmes, and all need to be evaluated for the best outcomes for the population.

Conclusion
It is claimed that over 12,000 lives per year could be saved if everyone achieved a healthy BMI.(8) It is also claimed that the UK is the fattest country in Europe.(9)
Interventions are needed at all levels, but the priority surely must be primary prevention in childhood. NICE published a clinical guideline in December 2006 entitled Obesity: The Prevention, Identification, Assessment and Management of Overweight and Obesity in Adults and Children. The focus is on monitoring and measuring when children enter school, rather than monitoring regularly from birth.
One could argue that appropriate programmes should be offered at the first assessment, rather than subjecting everyone to the same linear pathway, but it can be very difficult to judge which will be most effective for a particular client.
Programmes used in combination also seem to be recommended, as these tackle both the internal and external causative factors. Wadden et al compared four groups, using drug therapy and lifestyle change alone, and in combination.(10) Combining drug therapy and lifestyle interventions was clearly the best approach and achieved a sustained improvement even when contact was minimalised. A public health prevention programme is needed, but the fact that few Quality and Outcome Framework (QOF) points are assigned to measuring and tackling obesity-related states is unhelpful.
At a time when PCTs are looking closely at deficits and cost savings, the importance of assigning adequate resources to this key issue must be reiterated, not only from the public health community, but also from us all.

Resources

  1. WHO. Obesity: preventing and managing the global epidemic. Geneva: WHO; 1998.
  2. WHO. Global strategy on diet, physical activity and health. Geneva: WHO; 2004.
  3. Duke University Medical Center. Anti-depressant use associated with increased risk for heart patients. Durham, North Carolina: DUMC; 2006. Available from: http://www.sciencedaily.com.
  4. McCarthy HD, Cole TJ, Fry T, Jebb SA, Prentice AM. Body fat reference curves for children. Int J Obes 2006;30:598-602.
  5. Hunking P. Weight loss diets: what does the science say? J Commun Nurs 2006;20(5):29-33.
  6. Cummings D, et al. Gastric bypass for obesity: mechanisms of weight loss and diabetes resolution. J Clin Endocrinol Metab 2004; 39(6):2608-15.
  7. Kopelman PG, Grace C. New thoughts on managing obesity. Gut 2004;53:1044-53.
  8. NHS Centre for Reviews and Dissemination, University of York. The prevention and treatment of obesity. Effective Healthcare 1997;3(2).
  9. Lang T, Rayner G. Obesity: a growing issue for European policy. J Eur Soc Policy 2005;15:301-27.
  10. Wadden T, Berkowitz RI, Womble LG, et al. Randomized trial of lifestyle modification and pharmacotherapy for obesity. N Engl J Med 2005;353:2111-20.


Resources

Diet programmes

Fatmanslim
W: www.fatmanslim.com 
Free, including MP3 downloads. Men only

Weightwatchers
W: www.weightwatchers.com
Aims for weight loss of 2lb a week. £39.90 per month

Closerdiets
W: www.closerdiets.com  £10 per month. Free initial assessment

eDietsUK
W: www.edietsuk.co.uk  Personalised meal plans and 24-hour support

Sparkpeople
W: www.sparkpeople.com  Free, with motivational techniques and exercises