Helping Patients to Lose Weight

Obesity (or being overweight) is the excess accumulation of body fat. This is an important public health problem¹ as it is associated with increased risk of hypertension, coronary heart disease, type 2 diabetes, cerebrovascular event, gall bladder disease, certain cancers, osteoarthritis and sleep apnoea.² The World Health Organisation (WHO) classification of weight has fewest limitations, is most practical for adults and is most widely accepted. It is based on the body mass index (BMI).³

In 2002 23% of men and 25% of women were classed as obese.⁴ This represents a trebling since 1980, when 6% of men and 8% of women were classed as obese. NICE has produced guidance for obesity management in primary care.⁵

Advice and/or treatment should be offered to:⁶

• Adults with body mass index (BMI) greater than 30 kg/m²
• Adults with BMI greater than 28 kg/m² with co-existing conditions e.g. coronary heart disease and diabetes
• Parents of 'overweight families' - may need more intensive support
• People who self-refer - where appropriate

Changing any addictive behaviour involves progression through five stages:

• Pre-contemplation
• Contemplation
• Preparation
• Action
• Maintenance

People usually move through these stages several times before achieving their goal.⁷ It may be useful to assess where the patient is within this cycle, to monitor progress. People who are motivated (within a contemplation or preparation stage) are most likely to lose weight successfully. If this is not the case, after advising the benefits of weight loss, the patient should be encouraged to return when they feel ready.

• Health benefits:
  • Emphasise that 10% weight loss will have significant health benefits (reduced mortality, lowered BP, reduction in total cholesterol and triglyceride, increase in HDL cholesterol and better diabetic control) - the "10% solution".
• Realistic goals:
  • No longer necessary to aim for an ideal weight.
  • 0.5kg per week loss is adequate.
• Do not weigh too frequently:
  • Weekly is sufficient and small increases may be due to fluid retention.
• Encourage to take pride in appearance:
  • Looking good makes you feel good and less likely to comfort eat.
• Group support and counselling:
  • A combination of dietary and exercise advice, supported by behavioural therapy is more effective than diet or exercise advice alone.
  • Consider referral for cognitive-behavioural therapy, especially in children.⁸

The Department of Health has published supportive literature for primary care, which includes the following tools; Obesity care pathway, 'Losing weight, feeling great' booklet, 'Why lose weight?' card.⁹

• Counselling:
  • Weak evidence that counselling sedentary people increases physical activity, compared with no intervention.
• Exercise specialist:
  • Limited evidence that consultation with an exercise specialist, rather than a physician, may increase physical activity at one year.
• Specific advice:
  • Emphasise 30 minutes a day (even in 10 minute bursts) for 5 days a week is needed for general health.
  • It is likely that, for many people, 45-60 minutes of moderately intensity physical activity a day will be needed to prevent obesity.¹⁰
• Walking:
  • Distance more important than speed.
  • Slowly for 5 minutes to warm up, then 10 minutes is enough to start, gradually increasing the time without straining the body.
  • Advise to use a pedometer to help meet activity targets.
• Other activities:
  • Cycle instead of using the car.
  • Exercise bike/rowing machine whilst watching TV or listening to music.
  • Group activity such as aquarobics can be combined with physiotherapy.
  • "Exercise prescription" - local initiatives to issue prescriptions for supervised exercise programmes at fitness centres may combine group support with the "exercise specialist" listed above.

Emphasise the benefits of regular meals and providing a balanced, varied diet for the whole family. This should include at least 5 portions of fruit and vegetables per day:

• Suggest ways of reducing dietary fat:
  • Avoid fried food and instead choose grilled, boiled or baked food.
  • Use semi-skimmed milk, low-fat spreads and lean meat.
  • Choose healthy snacks such as fruits as alternatives to sweets and crisps.
• Serve smaller portions.
• Choose whole foods that take time to eat e.g. fruits and wholemeal bread.
• Reduce alcohol intake.
• Choose water (or low-calorie drinks) instead of high-sugar drinks.
• Use a food diary and locally approved advice sheets to ensure consistency of messages:
  • These are structured diet plans normally consisting of two meal-replacement drinks plus a self-prepared evening meal, fruit and vegetables.
  • They provide approximately 1200-1400 kcal daily.
  • Contact the local dietetic department for guidance.
• Very low calorie diets:
  • Consider only after failure of conventional diets.
  • Ensure they provide a minimum of 400 kcal/day for women, 500 kcal/day for men.
  • May be suitable in the hospital setting pre-operatively, but are no more successful over the longer term.

Orlistat, sibutramine and rimonabant are available on NHS prescription in the UK for treating obesity, and orlistat is also available directly from pharmacists.

Orlistat

Orlistat is a pancreatic lipase inhibitor that inhibits triglyceride digestion and reduces fat absorption by approximately 30%:

• It may have unacceptable side effects e.g. faecal incontinence.
• NICE recommends use only in patients who have lost ≥2.5 kg over previous 4 weeks by conventional diet and exercise regimen and:⁵
  • Have BMI ≥28 with co-existing related morbidities (hypertension, type 2 diabetes, hyperlipidaemia) despite adequate treatment.
  • Have BMI > 30 without above.
  • Weight loss required is at least 5% of initial bodyweight at 3 months and 10% of initial bodyweight at 6 months.
  • Aged 18-75 years.

Sibutramine

Sibutramine is a centrally-acting serotonin and noradrenaline re-uptake inhibitor, which is thought to promote satiety and stimulate energy expenditure:

• NICE recommends use only in patients with above weight problems who have made serious efforts to lose weight and who have received relevant professional help and undergo close monitoring of response to treatment.⁵ Pulse and blood pressure should be monitored.
• Also effective in weight maintenance, but regain on cessation of treatment. Requires weight loss at least 2 kg at 1 month and 5% of initial bodyweight at 3 months.
• May be used for 18-65 years for maximum of 12 months.

Combination therapy with sibutramine and orlistat is not recommended. There is very little evidence regarding the efficacy or safety of this combination.

Rimonabant

Rimonabant is a selective cannabinoid 1 (CB1) receptor antagonist.¹¹ It is licensed as an adjunct to diet and exercise for the treatment of obese adults (BMI 30 kg/m² or greater) or overweight adults (BMI greater than 27 kg/m²) with associated risk factors.¹² It should be continued beyond 6 months only if the person has lost at least 5% of their initial body weight since starting treatment.
There have been reports of risks of suicidal behaviour and depression associated with its use.¹³

Others

• Other centrally acting appetite suppressants - phentermine, dexfenfluramine, fenfluramine, mazindol, diethylpropion - promote modest weight loss, but associations with heart and lung problems and other drug-specific side effects mean they are largely unlicensed or actually banned. They are also drugs of potential abuse. The combination of fenfluramine and phentermine, known as "fen-phen" was formerly popular in the 1990's. The roughly equivalent chinese herbal remedy ephedra is regarded as a dangerous dietary supplement by the FDA.
• Fluoxetine: promotes modest weight loss, but SSRIs are associated with uncommon but serious adverse events.
• Phenylpropanolamine (PPA)is a nasal decongestant that is also found in appetite suppressants and in the excessive dosages used has been associated with a risk of haemorrhagic stroke.

• NICE guidelines include advice on referring morbidly obese patients for surgery.⁵ People are said to be morbidly obese if they have a body mass index (BMI) equal to or greater than 40 kg/m², or if the BMI is between 35-40 kg/m² and they have significant comorbid conditions that could be improved by weight loss.⁵
• Bariatric surgery is also recommended as a first-line option (instead of lifestyle interventions or drug treatment) for adults with a BMI of more than 50 kg/m² in whom surgical intervention is considered appropriate.
  • Patient has been receiving intensive management in a specialised hospital obesity clinic.
  • They are aged 18 years or over.
  • There is evidence that all appropriate and available nonsurgical measures have been adequately tried but have failed to maintain weight loss.
  • There are no specific clinical or psychological contraindications to this type of surgery.
  • They are generally fit for anaesthesia and surgery.
  • They understand the need for long-term follow-up.
  • There is no upper limit for age when considering bariatric surgery.
  • The potential benefits of bariatric surgery need to be weighed against the risks for complications and death.

Surgical options:

• Restrictive stomach surgery - application of bands or staples, vertical banded gastroplasty, which can be carried out by laparoscope.
• Bypass surgery to reduce adsorption - Roux-en-Y gastric bypass (actually combines restriction with bypass, commonest and most successful) and biliopancreatic diversion (BPD), suffer from "dumping" and nutritional deficiencies (B12, folate, iron, calcium, and for BPD Vits A,D, & K).