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Obesity: looking at it from the patient's point of view

The Obesity Awareness and Solutions Trust (Toast)
PO Box 6430
Harlow
Essex CM18 7TT
T: 01279 866010
E: enquiries@toast-uk.org.uk
W: www.toast-uk.org.uk

Most of the increased media attention surrounding obesity results from the publication of the National Audit Office Report Tackling Obesity in England, in February 2001.(1) This highlighted the costs of obesity, in terms of both the financial drain to the NHS and the actual human cost; for example, the extent of the comorbidities and social consequences for the obese individual. The report was based on data gathered in England in 1998 and included some of the following facts:

  • Obesity has tripled since 1980.
  • Obesity is escalating faster in England than any other European country.
  • 20% of the adult population are obese.
  • Two-thirds of the population are overweight.
  • It is predicted that in the next eight years 25% of the population will be obese.
  • Obesity seriously endangers health.
  • The annual cost of obesity to the NHS is 0„50.5bn for the treatment of conditions such as hypertension, type 2 diabetes, stroke, angina, certain cancers, coronary heart disease, anxiety and depression, and others.
  • The annual cost to the wider economy is 2bn.
  • Obesity causes 30,000 deaths a year. That is one death every 17.5 minutes.
  • Obesity reduces life expectancy by nine years.

The report also identified that few general practices had a coherent protocol in place for the management of obese patients. It identified that:
"...73% of general practitioners believed that there was a lack of proven, effective interventions available to assist them in determining the most appropriate treatment pathways for their patients."
Most GPs said that they would find a set of national guidelines useful.
The National Service Framework for coronary heart disease set milestones for the auditing and treatment of obesity.(2) The first was that: "All NHS bodies working closely with local authorities will have agreed and be contributing to the delivery of the local programme of effective policy on...reducing overweight and obesity by April 2001."
Second, they will have "quantitative data, no more than 12 months old, about the implementation of the policies on...reducing weight and obesity by April 2002."
With seven million obese adults in England alone (a number that increases by 1,000 a day), this is an immense task to be undertaken by an already underresourced service. Many nurses will be familiar with the comorbidities associated with obesity and of some of the treatments that are available to assist obese people to lose weight.

Treating obesity
There are various drugs on the market, such as those that reduce the appetite - sibutramine (Reductil from Abbott) - and those that prevent the absorption of fat - orlistat (Xenical from Roche). There are also surgical interventions available through obesity clinics, including stomach stapling, lap banding and waist cording, although only approximately 200 surgical interventions were carried out by the NHS last year. The National Institute for Clinical Excellence (NICE) is currently reviewing the clinical and cost-effectiveness of surgery for people with morbid obesity, which will undoubtedly raise the profile of obesity surgery accordingly.
The traditional intervention for the treatment of obesity has been to give people diet and exercise sheets and promote the "eat less, exercise more" message. Of course, for weight loss in an individual to occur, their output of energy needs to exceed their intake of calories.
It could be argued that by putting the emphasis on the food rather than the reasons behind the overeating in the first place, diets serve only to exacerbate weight problems and result in weight gain and "yo-yo" dieting. Research indicates that without a weight management programme, nine out of 10 people who lose weight put it all back on again within a year.

Society's opinion of the overweight
There is immense social pressure on individuals to conform to certain ways of dressing and to be a particular size. In general, obesity and overweight are seen in a negative way in the Western world, and assumptions are made and individuals judged because of their weight. Many obese people experience life as outsiders in a society that frequently rejects them. Not only is Obesity is not just a health concern: it is also a social problem.
When shown pictures representing a range of disabilities, both children and adults indicate that obesity is the type of disability that they would least prefer.(3) Obesity creates obstacles to marriage, employment and promotion.(4) By the time they reach school age, children become "sensitised" to obesity and associate it with a number of negative characteristics, such as laziness and sloppiness. Children's perceptions of thinness and overweight echo the prejudice against overweight that is voiced by society.

The obese patient
Eating disorders such as anorexia nervosa and bulimia nervosa are now recognised as being emotional disorders with physical symptoms. The treatment of these illnesses comes from within the psychiatric services. There are many shared attitudes that individuals with obesity, anorexia and bulimia suffer pertaining to shape and weight. In essence, people with these conditions are likely to experience overvalued ideas of their self-worth in terms of their shape and weight, which impact on how they think, feel and behave. An example of this may be seen when considering the following values and beliefs:

  • I must be thin because to be thin is to be successful, attractive and happy.
  • I must avoid being fat because to be fat is to be a failure, unattractive and unhappy.
  • Self-control is good because it is a sign of strength and discipline.
  • Self-indulgence is bad because it is a sign of weakness and indiscipline.

Such beliefs and attitudes will inevitably impact on the individual's feelings and behaviour. Typically, a failure to control weight and shape through overeating (control loss) may manifest itself in terms of depression, anxiety and social avoidance. Sufferers are likely to reinforce negative self-regard and low self-esteem through a perceived sense of hopelessness at having failed to achieve a sense of control.
Obesity has recently been recognised as a medical condition. However, most individuals are offered treatment for the associated illnesses rather than the obesity itself. The focus is placed on short-term weight loss rather than the reasons why the individual has been using food in the way that they have. As well as looking at the observable behaviour, such as how much food an individual consumes, it is vital to look at what drives food choices - the cognitions and emotions that lie behind.
Many obese people recognise that there is a strong link between the problems they describe and the problems of those with a drink problem. They describe feeling out of control around food and recognise that there is an addictive element to their use of food. They describe relying on food as a reliever of stress, to calm anger, to celebrate, to rebel, to reward themselves, to fill an emotional void, to make them feel better and to comfort themselves.
It is universally recognised that an alcoholic would not be "cured" of their alcoholism by being given information about the correct amount of alcohol that should be consumed, or about the content or labelling of an alcoholic drink to enable them to find the one with the least alcohol content in the supermarket. The alcoholic does not drink to excess because they are thirsty. Likewise, for many obese people, physical hunger is not the cause of their overeating. Yet the main message that is given to the obese is to restrict their food intake, which is as difficult as cutting down on alcohol would be for an alcoholic.
With all the initiatives for treating obesity, it is important to realise that no "one size fits all". It is a complex problem; one weight loss treatment may work well for one, but not for another. Much evidence suggests that "just" going on a diet may well produce a weight loss but that many will regain the weight if they do not also work on the underlying causes of their weight issues. Treating the symptoms alone will rarely provide long-term solutions. Most alcohol programmes include some form of counselling; they also help people to recognise why they have been overconsuming and to find other coping mechanisms, helping clients to build belief in themselves.
It is essential for practitioners to identify both the physical and psychological characteristics of the obese person. A person-centred approach, using empathy and active listening, is essential. Many obese people will have been dismissed in the past and will feel worthless or at least worth less than others. It is essential to enable obese people to access the appropriate services to meet their needs. This will involve both the public and private sectors. It is important to remember the underlying psychological issues that result in obesity when looking at treatment options, and it is vital to recognise that the obese person is the "dieting expert" themselves.

References

  1. National Audit Office. Tackling obesity in England. London: National Audit Office; 2001.
  2. Department of Health. The National Service Framework for coronary heart disease. London: Department of Health; 2000.
  3. Richardson SA, Hastorf AH, Googman N, Dornbusch SM. Cultural uniformity in reaction to physical disabilities. Am Sociol Rev 1961;90:44-54.
  4. Elder GH. Appearance and education in marriage and mobility. Am Sociol Rev 1969; 34:519-533.

Resources
Eating Disorders Association
103 Prince of Wales Road
Norwich NR1 1DW
Adult Helpline: 0845 634 1414
Youthline: 0845 634 7650
W:www.edauk.com
British Nutrition Foundation
High Holborn House
52-54 High Holborn
London WC1V 6RQ
T:020 7404 6504
E:postbox@nutrition.org.uk
W:www.nutrition.org.uk
National Obesity Forum
PO Box 6625
Nottingham NG2 5PA
T:0115 8462109
E:national_obesity.forum@ntlworld.com
W:www.national obesityforum.org.uk