Levels of overweight and obesity have reached epidemic proportions in the UK, in the developed world only the US has a higher prevalence of obesity so what can GPs and other primary care professionals do to redress the balance?
Childhood obesity is recognised globally as one of the most serious public health challenges of the 21st Century. Without appropriate intervention obese children are in danger of becoming obese adults, and consequently at risk of developing conditions associated with obesity, such as type 2 diabetes, cardiovascular disease, stroke, hypertension, musculo-skeletal problems, gynaecological disorders and some cancers, notably endometrium, breast, kidney and colon. Obese women risk infertility, as well as stillbirth and preterm birth. Obesity also predisposes people to psychological conditions exacerbated by low self esteem such as depression and anxiety. Levels of overweight and obesity have reached epidemic proportions in the UK. Of nations in the developed world only the US has a higher prevalence of obesity. Recent figures from Public Health England show that two thirds of the adult population is affected as well as one third of children aged between two and 15 years.1 The situation in Scotland, Northern Ireland and Wales is no better. British girls and boys are among the most obese children in Europe.2 Forecasts suggest that by 2030 almost three quarters of British men and two out of three British women will be overweight or obese.3
Conditions directly related to obesity result in around 30,000 deaths and 18 million days of sickness every year. As well as the toll on individuals’ health and wellbeing, more than £5 billion of the NHS budget is spent annually on the health problems associated with obesity.4
This figure is set to double by 2050.
Although not all the causes of obesity are fully understood, it is largely preventable, being a consequence of our increasingly sedentary lifestyles and heavy reliance on fast foods, such as takeaways, that are often high in fats and sugars. For this reason the World Health Organization urges us all to adopt healthier lifestyles by rebalancing our diets so that we reduce our energy intake from fats and sugars, while increasing our consumption of fruit and vegetables, together with legumes, whole grains and nuts. Engaging in regular physical activity is also essential if we are to maintain good health. From a clinical perspective the terms ‘overweight’ and ‘obese’ are used when excess fat represents a threat to health. The body mass index (BMI) is the internationally recognised standard for measuring this. (See box 1).
By 2020 the government hopes to see a sustained fall in the levels of obesity in both adults and children. While the strategy involves a ‘whole systems’ approach across both the public and private sectors, the health service is seen as having a vital role in achieving the significant reduction required.5 In particular the importance of primary care is stressed by the National Institute for Health and Clinical Excellence (NICE): “Managers and health professionals in all primary care settings should ensure that preventing and managing obesity is a priority, at strategic and delivery levels. Dedicated resources should be allocated for action.”6 This is reflected in one of the domains of the quality and outcomes framework (QOF) for 2014/15, which rewards general practices for establishing and maintaining “a register of patients aged 16 or over with a BMI ≥ 30 in the preceding 12 months”. Identifying obese patients is one of the key activities that practices need to adopt.
These activities are highlighted in the service model for the prevention and management of overweight and obesity that is based on a tiered approach. Thresholds and criteria vary across the country, and level three services in particular are not available everywhere. However, primary care is integral to successful outcomes at all levels, since patients receiving specialist intervention, including surgery, will continue to need support and monitoring from their local practices. It is intended that the vast majority of overweight or obese patients will receive their care at levels one or two. (See box 2).
Although all healthcare staff are encouraged to raise weight management issues with patients, where appropriate, this is most likely to occur in primary care settings where 90% of NHS contacts take place.
Adults and children often have a unique relationship with primary care professionals through routine contacts at specific stages of life, such as pre and postnatally, in infancy and childhood, as well as contacts in relation to time-limited or enduring physical or psychiatric conditions. Using their knowledge of an individual’s personal circumstances and medical history, primary care staff are well placed to identify and advise those whose health is at risk from excess weight. This will also include patients suffering from conditions such as diabetes and polycystic ovary syndrome that predispose to weight gain, as well as those taking medications that can increase appetite; for example, steroids and antipsychotics.
Practices can enable staff to support their patients through:
- Appropriate education and training, including access to specialist training, such as motivational interviewing, for those developing a special interest in weight management.
- Good communication to highlight local partnerships and initiatives such as evidence-based weight loss programmes in the community.
- Clear and accessible guidance for both patients and staff in relation to strategies for maintaining a healthy weight, including practical examples.
- Up-to-date protocols for referral to specialist care.
- All healthcare professionals need to have sufficient understanding of the key issues relating to overweight and obesity, as well as relevant consultation skills, so that they can use opportunistic contacts as well as routine ones to:
- Give appropriately personalised lifestyle advice focusing on the importance of good nutrition and regular exercise.
- Signpost motivated individuals to community weight management programmes based on best practice principles.
- Refer patients for specialist advice and treatment including psychological support.
- Support patients engaged in weight loss programmes, including those who have undergone bariatric surgery.
The highest levels of obesity in the country tend to correlate with those areas where deprivation is greatest, but all practices need to consider the implications of treating obese patients. These include:
- Access issues; for example, appropriately wide entrances to accommodate wider wheelchairs.
- Seating and toilet facilities that can accommodate weights greater than 150 kg.
- Wider than standard examination couches.
- Scales capable of weighing people up to 200 kg.
- Provision of suitable medical equipment; for example, very large blood pressure cuffs.
- Appointment systems with sufficient flexibility to enable planned visits, at fortnightly or monthly intervals, to facilitate the close monitoring and follow-up required for some patients.
In addition to these practical issues it is important that all staff recognise the need to be culturally sensitive and non-judgemental. Obese patients should not feel stigmatised, and it should be recognised that some may not be ready to engage with a weight management programme when it is first suggested to them. It is not uncommon for complaints to arise where lifestyle issues requiring behaviour modification are misinterpreted, or where professionals have underestimated the impact that such discussions can have on an individual.
Involving staff in developing a ‘healthy lifestyle strategy’ for the practice may generate some innovative ideas. These might include:
Practice based health and fitness groups, open to all, or focused on the needs of particular patients, such as those with type 2 diabetes.
Using the practice website, intranet and Facebook page for health promotion initiatives, providing practical examples to show how increased activity and healthy eating can be incorporated into daily living. (See resources)
The practice can also support staff who are trying to reduce weight or maintain a healthy lifestyle by:
Providing changing facilities and secure storage areas for cycles.
Negotiating discounted memberships for local gyms and fitness clubs.
Ensuring breaks allow sufficient time for moving around and eating appropriately.
There is a powerful analogy to be made between obesity today, and the serious threat to health from smoking that was recognised a generation ago. Smoking and obesity both shorten lives and have significant long term adverse effects on health, but while the prevalence of smoking is reducing, the opposite is true in relation to obesity. As well as sustained public health and political initiatives, individual interventions
in general practice are vital if we are to turn the tide on the obesity epidemic.
Resources
Centre for Public Health Excellence. NICE Public Health Guidance 47. Managing overweight and obesity among children and young people: lifestyle weight management services. National Institute for Health and Clinical Excellence, 2013.
National Collaborating Centre for Primary Care and the Centre for Public Health Excellence at NICE. Clinical Guideline 43. Obesity: Guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. National Institute for Health and Clinical Excellence, 2006.
Royal College of Physicians. Action on obesity: comprehensive care for all. Report of a working party. London: Royal College of Physicians, 2013.
References
Mandalia D. Children’s BMI, overweight and obesity. Health Survey for England 2011, Health, social care and lifestyles; 2012, The Health and Social Care Information Centre.
Ng M et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet, Early Online Publication, 29 May
2014 DOI: 10.1016/S0140-6736(14)60460-8.
Webber L, Divajeva D, Marsh T et al. The future burden of obesity-related diseases in the 53 WHO European- Region countries and the impact of effective interventions: a modelling study. BMJ Open 2014;4:e004787. doi:10.1136/bmjopen-2014- 004787
McCormick B1, Stone I, Corporate Analytical Team. Economic costs of obesity and the case for government intervention. Obes Rev. 2007;8 Suppl 1:161-4.
Ellison J. Reducing Obesity and Improving Diet. https://www.gov.uk/government/policies/reducing-obesity-and-improving-diet. Crown Copyright, Published 25th March 2013.
National Collaborating Centre for Primary Care and the Centre for Public Health Excellence at NICE. Clinical Guideline 43. Obesity: Guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. National Institute for Health and Clinical Excellence, 2006.
