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Weight management: helping obese patients

Stephen Kreitzman
PhD RNutr
UK Registered Nutritionist

Valerie Beeson
Clinical Programme Director
Howard Foundation Research Ltd
Cambridge

There is a lengthy list of common medical conditions that are either caused by or exacerbated by obesity. At the very top of that list is type 2 diabetes, which is virtually 100% reversibly related to excess weight. Treating the weight is treating the disease. Treating the weight could also be considered as preventing the disease. By 2010, three million people will be diagnosed as having diabetes, and 80% of them will die prematurely from cardiovascular disease.(1)
Type 2 diabetes is even increasing in children; the condition is considered serious enough by NICE that surgical intervention is being countenanced for children. Most of the agents used in diabetes treatment are known to cause an increase in weight. Current treatment protocols often encourage immediate selection of treatments that invariably result in yet further weight gain and perpetuation of the disease.

Morbid obesity minus 5% is still pretty fat
What advice should we give to a 23-stone patient? Should the advice be different if this patient was 25 stone a year ago? There is a very high probability that clinical judgement would not recognise much difference. This patient is still dangerously fat, despite having lost the 5% of initial weight that may have been the treatment expectation.
Even worse, an obese patient will usually shift 5% of body weight or more of stored glycogen and water upon dieting. Fat loss at this level can be essentially nil. With repletion of glycogen stores upon termination of the "diet", the lost weight can rapidly return. It can almost seem as though there is a "set point" for body weight.

Being really effective with obese patients
Pharmacists are already proving that substantial weight loss and long-term weight maintenance can be an expected norm under pharmacy conditions. Weight loss will drastically reduce the advance of type 2 diabetes. It will help deal with hypertension. It will permit patients to gain access to elective surgery. Excess weight is a common and powerful constraint on quality of life. It is in the best interest of patients and the NHS as a whole to support and encourage initiatives in managing body weight.
It is also reasonable to expect clinically meaningful results for obese patients. While any weight loss can be argued to improve relative risk of diseases or premature death, patients anticipate real help from medical professionals. Before selecting a course of treatment, determine whether the published results for the treatment or previous experience provide a realistic expectation that the patient really will lose sufficient weight and not be faced with the probability of nutrient deficiencies. The need is to reduce food intake sufficiently; to use up enough previously eaten calories that are now stored as fat, and at the same time prevent malnutrition - the human body requires a full complement of nutrients.

Patients need to accept a substantial reduction in calorie intake
Patients would love to find a way around some very simple laws of physics, but sadly it is impossible. In order to lose weight they really have to eat fewer calories than they are using, regardless of whether the calories are from carbohydrates, fats or proteins. It takes an enormous amount of physical effort to use up the calories (3,500kcal) in a single pound of body fat. Since a mile run only consumes about 100kcal, a 35-mile run is required. The only practical means of dealing with a substantial weight problem is by severely restricting intake. Increased activity levels are very important in the long term but are more possible as the patient achieves a reasonable weight.
Since food restriction has much in common with restriction in other manifestations of addiction, withdrawal is not simple, especially in an environment where there is continued presence of the substance of abuse. Customary approaches to weight management are failing worldwide, leading to much wringing of hands and apportioning of blame. At the same time, many of your pharmacy colleagues are quietly having an impact. If there really are going to be three million diagnosed cases of type 2 diabetes in the UK in 2010, they could really use some help.

Reference

  1. Practice: Parental role in ending child obesity. GP Magazine 2005;11:38.