When to refer
If after using a proven lifestyle weight management programme, patients have not reached their weight loss targets then other interventions should be considered. These will be covered in a future module but are mentioned briefly below.3
Drug therapy
NICE 2006/SIGN recommend drug therapy (with orlistat) should be considered on an individual basis (following risk/benefit assessment) and discussion as an adjunct to lifestyle interventions in the management of weight loss in patients with a BMI >/= 28 kg/m2 with comorbidities or BMI >/= 30 kg/m2. Therapy should be continued beyond 12 weeks for as long as there are clinical benefits if the patient has lost 5% of their initial body weight since starting drug treatment.
Surgery
Bariatric surgery should be considered on an individual case basis if the patient has completed a weight management programme involving diet, exercise, psychological and drug intervention. These patients should be referred on for assessment by a multidisciplinary team. Candidates for surgery include those with:
- a BMI of 40 kg/m2, or a BMI 35 kg/m2 and has at least one severe comorbidity which would be expected to improve significantly with weight reduction
- non-surgical measures have been tried but have to failed to achieve or maintain adequate, clinically beneficial weight loss for at least six months.
Surgery can be considered as a first-line option in adults with a BMI of 50 kg/m2 or more with drug therapy considered before surgery if waiting time is long.
IAPT
NICE-approved IAPT (Improving Access to Psychological Therapies) services are now available on the NHS as part of a stepped care approach and have been shown to have a beneficial effect on clinical outcomes. The IAPT website contains detailed information on these services and their availability throughout the UK.
Summary: key messages
- Obesity is increasing year on year – 2012 figures show 62% of adults were overweight or obese
- Obesity is associated with many comorbidities and reduces life expectancy by between two to 10 years
- Obesity cost 6% of the total NHS budget in 2007 and is increasing every year
- A BMI >30 kg/m2 is considered obese in Caucasians with certain ethnic groups considered at risk at a lower BMI
- Central adiposity is a useful indicator of increased risk when waist circumference >94 cm in men and >80 cm in women
- The GP has a pivotal role to play in the prevention and management of overweight and obesity
- Better medical education and continuing professional development is needed in this area
- Knowing when to raise the issue of overweight and obesity with patients, and doing so with empathy, is crucial in its management
- Targets for weight loss should be introduced gradually in small, achievable steps. People should aim to lose 0.5–1 kg of body weight per week with a target of 5% of body weight lost. Healthy levels of physical activity are five 30-minute sessions of moderate physical activity per week with increasing time spent for weight loss
- It is crucial to change behaviour around food and activity
- Group weight loss programmes meeting the core components recommended by NICE are effective and can be prescribed
- Follow-up and support is essential for the success of any programmes and for weight loss to be maintained long term.
close window and return to take test
References
1. Royal College of Physicians. Action on obesity: comprehensive care for all. Report of a working party. London: RCP, 2013. Available in full from https://www.rcplondon.ac.uk/sites/default/files/action-on-obesity.pdf
2. Butland B, Jebb S, Kopelman P, et al.; Government Office for Science. Foresight: tackling obesities: future choices – project report (2nd Edition). Crown Copyright 2007. Available in full from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/287937/07-1184x-tackling-obesities-future-choices-report.pdf
3. NICE clinical guideline 43: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. National Institute for Health and Clinical Excellence 2006. Available in full from http://www.nice.org.uk/CG43
4. Lobstein T, Jackson Leach R. Government Office for Science. Tackling obesities: future choices – international comparisons of obesity trends, determinants and responses – evidence review. Crown Copyright 2007. Available in full from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/295684/07-926A2-obesity-international.pdf
5. Public Health England. UK and Ireland prevalence and trends. National Obesity Observatory 2014. Available in full at http://www.noo.org.uk/NOO_about_obesity/adult_obesity/UK_prevalence_and_trends
6. Public Health England. Slide sets for adult obesity. National Obesity Observatory 2014. Available in full at http://www.noo.org.uk/slide_sets
7. Craig R and Mindell J (eds) (2008) Health Survey for England 2006. London: The Information Centre. Available from www.ic.nhs.uk/pubs/hse06cvdandriskfactors
8. Craig R and Shelton N (eds) (2009) Health Survey for England 2007. London: The Information Centre. Available from www.ic.nhs.uk/pubs/hse07healthylifestyles
9. Craig R, Mindell J, Hirani V (eds) (2009) Health Survey for England 2008, London: The Information Centre. Available from www.ic.nhs.uk/pubs/hse08physicalactivity
10. Craig R, Hirani V (eds) (2010) Health Survey for England 2009, London: The Information Centre. Available from www.ic.nhs.uk/pubs/hse09report
11. Craig R, Mindell J (eds) (2011) Health Survey for England 2010, London: The Information Centre. Available from www.ic.nhs.uk/pubs/hse10report
12. Gatineau M, Mathrani S. Obesity and ethnicity. Oxford: National Obesity Observatory 2011. Available in full at http://www.noo.org.uk/uploads/doc/vid_9851_Obesity_ethnicity.pdf
13. Wang YC, McPherson K, Marsh T, Gortmaker SL, Brown M. Health and economic burden of the projected obesity trends in the USA and the UK. Lancet 2011;378:815–25. http://dx.doi.org/10.1016/S0140-6736(11)60814-3
14. McPherson K, Marsh T, Brown M; Government Office for Science. Tackling obesities: future choices – modelling future trends in obesity and their impact on health (2nd edition). Crown Copyright 2007. Available in full from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/295149/07-1662-obesity-modelling-trends.pdf
15. Dent M, Swanston D. Briefing note: obesity and life expectancy. National Obesity Observatory 2010. Available in full from http://www.noo.org.uk/uploads/doc/vid_7199_Obesity_and_life_expectancy.pdf
16. Diabetes UK:Diabetes in the UK 2012: Key statistics on diabetes. http://www.diabetes.org.uk/Documents/Reports/Diabetes-in-the-UK-2012.pdf
17. Obesity information. American Heart Association 2014. Available at http://www.heart.org/HEARTORG/GettingHealthy/WeightManagement/Obesity/Obesity-Information_UCM_307908_Article.jsp
18. Bhaskaran K, Douglas I, Forbes H, dos-Santos-Silva I, Leon DA, Smeeth L. Body mass index and risk of 22 specific cancers: a population-based cohort study of 5.24 million UK adults. Lancet 2014;384:755-65. http://dx.doi.org/10.1016/S0140-6736(14)60892-8
19. Obesity perception and policy: multi-country review and survey of policymakers 2014. European Association for the Study of Obesity 2014. Available in full from http://www.c3health.org/c3activities/documents/obesity-policymaker-survey-2014/
20. NICE guidelines PH53: managing overweight and obesity in adults – lifestyle weight management services. National Institute for Health and Care Excellence 2014. Available in full from http://www.nice.org.uk/guidance/ph53
21. David Haslam, National Obesity Forum – “personal communication”
22. NICE guidelines PH47: managing overweight and obesity among children and young people – lifestyle weight management services. National Institute for Health and Care Excellence 2014. Available in full from http://www.nice.org.uk/guidance/ph47
23. NICE public health guidance 46: assessing body mass index and waist circumference thresholds for intervening to prevent ill health and premature death among adults from black, asian and other minority ethnic groups in the UK. National Institute for Health and Clinical Excellence 2013. Available in full from http://guidance.nice.org.uk/ph46
24. Healthcare professionals: training resources – waist circumference. National Obesity Forum. Available in full online from http://www.nationalobesityforum.org.uk/healthcare-professionals-mainmenu-155/assessment-mainmenu-168/171-waist-circumference.html
25. Townsend N. Obesity and overweight surveillance in England: what is measured and where are the gaps? National Obesity Observatory 2009. Available in full from http://www.noo.org.uk/uploads/doc/vid_4483_Obesity_surveillance_data_-_Final_draft_12_11_09.pdf
26. The practical guide: identification, evaluation, and treatment of overweight and obesity in adults. National Heart, Lung, and Blood Institute, 2000. Available in full from http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf
27. GP ten top tips: raising the topic of weight. Royal College of General Practitioners 2012. Available in full from http://www.rcgp.org.uk/clinical/clinical-resources/nutrition/~/media/Files/CIRC/Clinical%20News/Top-Ten-Tips-Leaflet-2013.ashx
28. Derbyshire: http://www.northderbyshireccg.nhs.uk/assets/Clinical_Guidelines_/Lifestyle_/derbyshire_obesity_pathway_updated.pdf
29. Jebb SA, Ahern AL, Olson AD, et al. Primary care referral to a commercial provider for weight loss treatment versus standard care: a randomised controlled trial. Lancet 2011;378:1485–92. http://dx.doi.org/10.1016/S0140-6736(11)61344-5
30. Management of obesity: a national clinical guideline. Scottish Intercollegiate Guidelines Network, 2010. Available from http://www.sign.ac.uk/pdf/sign115.pdf
31. NOO data factsheet. Adult physical activity. National Obesity Observatory 2012. http://www.noo.org.uk/uploads/doc/vid_17580_AdultPAFactsheet.pdf
32. BCS 2014: British Cardiovascular Society 2014 Annual Conference. 2nd-4th June, Manchester. Presentation by Dr Marcus Smith, University of Chichester.
33. Trueman P and Flack S (2006) Economic evaluation of Weight Watchers in the prevention and management of obesity: NICE Conference
34. McCombie L, Lean MEJ, Haslam D; the Counterweight Research Group. Effective UK weight management services for adults. Clin Obes 2012;2:96–102. http://dx.doi.org/10.1111/j.1758-8111.2012.00049.x
35. Jolly K, Daley A, Adab P, Lewis A, Denley J, Beach J, Aveyard P. A randomised controlled trial to compare a range of commercial or primary care led weight reduction programmes with a minimal intervention control for weight loss in obesity: the Lighten Up trial. BMC Public Health 2010;10:439. http://dx.doi.org/10.1186/1471-2458-10-439
close window and return to take test
All rights reserved. No part of this programme may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publishers, Medinews (Cardiology) Limited.
It shall not, by way of trade or otherwise, be lent, re-sold, hired or otherwise circulated without the publisher’s prior consent.
Medical knowledge is constantly changing. As new information becomes available, changes in treatment, procedures, equipment and the use of drugs becomes necessary. The editors/authors/contributors and the publishers have taken care to ensure that the information given in this text is accurate and up to date. Readers are strongly advised to confirm that the information, especially with regard to drug usage, complies with the latest legislation and standards of practice.
Healthcare professionals should consult up-to-date Prescribing Information and the full Summary of Product Characteristics available from the manufacturers before prescribing any product. Medinews (Cardiology) Limited cannot accept responsibility for any errors in prescribing which may occur.
