This site is intended for health professionals only

The practicalities of weight management in primary care

Carolyn Forrest
BSc(Hons) SRD
Dietitian
Priory Medical Group
North Shields

We all know the bare facts; nearly 25% of adults in Britain are obese, obesity reduces life expectancy and is a major factor in many of the chronic diseases we treat.(1) We also know that it is a difficult problem to solve and most of us struggle to know how best to tackle it. The best approaches are based on the behaviour change cycle.
The first point is this; we can't make anyone lose weight! We can give out as many useful leaflets, and provide as much sensible advice about healthy eating, calorie reduction and exercise programmes as we like, but we still can't make anyone lose weight. We can only support, guide and encourage those people who have decided for themselves that they want to lose weight.

How do you feel about your weight?
Many people are sensitive about their weight so a useful, nonjudgmental opening such as "how do you feel about your weight?" is a good start. If the individual is at all concerned they have an opportunity to discuss things further. Never try to force someone who is not ready to tackle their weight; you can "roll with their resistance" by reflecting their negative comments back to them. This may prompt them to give the subject more thought.
If you detect they are concerned about their weight you can move the conversation on; I tend to ask about their past experiences of weight loss, what plans they have followed? What worked well? Why did things go wrong? Try to ask lots of open questions and listen rather than prescribing your solutions. If certain programmes worked well for them why reinvent the wheel? Try to help the person identify what stopped them from continuing to lose/control their weight and what could they do differently in the future; for example was the plan too different from their normal eating pattern and therefore not sustainable?
I frequently use a pros and cons list at this point to identify all the reasons for losing weight and what is stopping them. Try to help them to identify a strong personal motivation for weight loss to help them when things are difficult. Looking at what is stopping them from losing weight will help them to think through solutions and action plans.

The SMART plan
Planning and organisation are vital for successful weight loss. Help your patient come up with a SMART plan: Specific, Measurable, Agreed, Realistic and Time specific. Writing these down helps turn good intentions into action! Test the likelihood of the plans being put into action by assessing on a scale of 0-10 how confident they are. If they are less than seven, explore why and what can be changed to make them more likely to succeed.
Regular support is also vital for success but we can't necessarily provide it all. Weekly weight checks help the person assess whether their action plans are effective; we have scales in the reception area that give a printout of weight and body mass index (BMI) so people can have the discipline of a weekly weight check without the cost of joining a commercial slimming group. They can also have reviews with our healthcare assistant. You could explore text or email contact to support people without the need for actual clinic appointments.
People will lapse many times while trying to tackle their weight; this is normal (see Figure 1). The most important thing is to learn from it and move on!

[[nip37_fig1_67]]

Drug treatments
So where do drugs come in? The important thing for both patients and prescribers to realise is that they are not magic pills that will make someone lose weight. Think of them more like nicotine replacement therapy supporting a smoker while they make a difficult behaviour change. Obesity medication is helpful when someone has tried to lose weight but needs some additional support to continue with something they find difficult.
There are three types of obesity medication licensed for use on the NHS. You will also find dozens of others advertised in magazines and health shops; none of these is an evidence-based treatment and therefore should not be recommended. The three we can prescribe all work in very different ways and should be targeted for different patients.
Orlistat (Xenical [Roche]) inhibits intestinal lipase and prevents 30% of dietary fat from being absorbed; patients need to follow a low-fat eating pattern in order to avoid any unpleasant side-effects! Roche offers an excellent support package (MAP) to support patients and help them to reduce their fat intake. If patients find it difficult to resist certain high-fat foods, such as chocolate, cheese, pastry, chips, takeaway, and so on. Orlistat can very effectively help patients to avoid these foods and develop better eating habits. It can also help people identify foods they didn't realise had a high-fat content. Patients should be prescribed 120 mg orlistat to be taken three times a day with their meals.(3)
Sibutramine (Reductil [Abbott]) inhibits the re-uptake of serotonin and noradrenaline by the brain; it is a satiety enhancer and therefore patients are able to reduce their portion sizes without feeling hungry.(4) Abbott has a support package called "Change for Life", which can be accessed via a 12-week pack or online. If patients have already reduced their fat intake or have attended slimming groups before and are eating predominately low-fat foods, sibutramine can help them reduce their overall calorie intake. It only takes a slight imbalance between calorie intake and expenditure to lead to weight gain - one digestive biscuit a day over and above the calories burnt up can lead to a weight increase of 6-8 lb in a year! This explains why many people who feel they are "eating all the right things" still have a problem with their weight.
Patients prescribed sibutramine need to have a blood pressure less than 145/90 and it should be checked every two weeks for the first 12 weeks. It also must not be prescribed for patients on selective serotonin-reuptake inhibitors or for patients with heart, liver or kidney problems. The dose is 10 mg once a day and this can be increased to 15 mg if the patient does not lose 2 kg in the first month.
Rimonabant (Acomplia [Sanofi Aventis]) inhibits the endocannabinoid system; it blocks the CB1 receptors and reduces food cravings and is associated with improved glucose and lipid levels. As a result it may be beneficial for patients with metabolic syndrome. Sanofi Aventis also has a helpful support pack for patients called "It's What You Gain". Patients with a history of depression should not be prescribed rimonabant. NICE has not as yet reviewed rimonabant
Patients need to have a body mass index (BMI) greater than 30 (or 27/28 if comorbidities) in order to be prescribed obesity medication and it is very important to use it in conjunction with the relevant support programmes. It is also essential to have regular weight checks to ensure the person has lost 5% of their body weight in 12 weeks. If not the medication should be stopped.(3,4)

Conclusion
Weight loss is probably the most difficult thing we ask our patients to do. It can be both a frustrating and highly rewarding area of work to be involved in. One problem is how to define success; many of my patients will never achieve a "normal" BMI but even a modest weight loss (5-10% of original body weight) leads to tremendous improvements in both self-esteem and confidence as well as health benefits.
I would encourage you to audit what you do to see what works well and learn from what is less successful; in our clinic we discovered a significant number of patients did not make it to their first appointment. A phone call two to three days before the appointment means that nonattendance rates are nearly none as if the person does not want the appointment someone else is given it.
Share your successes with sceptical colleagues! Most of all be positive, nonjudgmental, enthusiastic and encouraging. Remember sometimes prevention of weight gain is success! Good luck!

References

  1. National Audit Office. Comptroller and Auditor General. Tackling obesity in England: executive summary and recommendations. London: TSO; 2001.
  2. Prochaska J, DiClemente C. Transtheoretical model/stages of change. University of South Florida; 1988. 
  3. National Institute for Health and Clinical Excellence. Orlistat for the treatment of obesity in adults. London: NICE; 2004.
  4. National Institute for Health and Clinical Excellence. Guidance on the use of sibutramine for the treatment of obesity in adults. London: NICE; 2004.