Helping Patients to Lose Weight

Obesity (or being overweight) is the excess accumulation of body fat. This is an important public health problem ¹, being associated with increased risk of hypertension, coronary heart disease, Type 2 diabetes, stroke, gall bladder disease, certain cancers, osteoarthritis, and sleep apnoea². The World Health Organization (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.

Advice and/or treatment should be offered to:⁵

• 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.
• Adults who are overweight coinciding with diabetes, other severe risk factors, or serious disease.
• Parents of 'overweight families'. They 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, and maintenance, and people usually move through these stages several times before achieving their goal⁶. 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 thus 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 ⁷.
• The Department of Health has published supportive literature for primary care, until the National Institute of Health and Clinical Excellence (NICE) publishes its guidelines on obesity, scheduled for 2007. This includes the following tools; Obesity care pathway,'Losing weight, feeling great' booklet,'Why lose weight?' card.

• 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 obesity⁸.
• Advise the person to use a pedometer to help meet activity targets.
• 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.
• 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 e.g. 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.
• Serving 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, and providing approximately 1200-1400 kcal daily). Contact the local dietetic department for guidance.
• Very low calorie diets: Consider only after failure of conventional diets, ensuring provide a minimum of 400 Cal/day for women, 500 Cal/day for men. May be suitable in the hospital setting pre-operatively, but are no more successful over the longer term.

• 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:
  1. Have BMI ≥28 with co-existing related morbidities (hypertension, type II diabetes, hyperlipidaemia) despite adequate treatment.
  2. Have BMI > 30 without above ⁹.
  3. Weight loss required is at least 5% of initial bodyweight at 3 months and 10% of initial bodyweight at 6 months.
  4. Age 18-75

• NICE, 2005 have guidelines for referring morbidly obese patients for surgery ¹¹. 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.
• Patient has been receiving intensive management in a specialized 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.
• 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).