Obesity module 1: management in primary care

How and when to raise the issue

Prejudices and judgemental attitudes that obesity is a lifestyle choice and a self-inflicted problem lead to stigmatisation of the people who are obese, contributing to feelings of abandonment, to poor quality of life and increased risks of psychiatric morbidity, all of which can exacerbate illness and healthcare costs.¹

Obese people may have low self-esteem and dislike their condition. Choosing the appropriate moment and respectful language to bring up the subject is therefore paramount. GPs and other healthcare professionals must identify when to raise weight management with a patient and do to so “confidently, but with empathy” according to NICE, ensuring that the tone and content of all communications is respectful and non-judgemental.²⁰ Terminology used to describe someone’s condition should respect how they like to be described.²⁰

The Royal College of General Practitioners’ has the following tips for how to raise the issue of weight management:²⁷

A protocol developed by NHS Derbyshire County has useful steps on how to assess a patient’s motivation to change and readiness to lose weight²⁸ (see appendix on Derbyshire model).

Motivational interviewing – where the healthcare professional can help harness the individuals own motivation to make progress from an ambivalent stage – can be a useful technique in encouraging people to move on to the next stage.²¹

Weight loss methods and targets

With the plethora of ‘diets’ and weight loss options headlined in the press on an almost daily basis, healthcare professionals should make sure any weight loss advice given is realistic, healthy and evidence-based. Encouraging healthy eating and increased physical activity should be recommended for all patients for its proven health benefits even when no weight loss is required. However, it is known that for weight loss, a structured intervention is required (rather than simply providing advice on healthy eating and physical activity).²⁹

A key issue in weight management is to help people to change their behaviour. Once a person’s willingness to change has been assessed, realistic targets and goals should be set, which are discussed in further detail later. Some general tips are:

• Realistic targets for weight loss are 0.5–1 kg a week with the aim of losing 5–10% of body weight – 5% loss can have a clinically significant impact on health outcomes
• Targets for exercise are at least 30 minutes of moderate physical activity at least five times a week for health benefits; longer sessions of 45–60 minutes a day are needed to prevent obesity, with sessions of 60–90 minutes daily likely to be needed to avoid weight regain.³

It is important that any advice given fits in with an individual’s needs and circumstances. Distinguish between health aspects and cosmetic concerns. Discussions should emphasise that any weight loss should be gradual, with long-term healthy changes to dietary habits and activity levels, as well as behaviour. Rein in unrealistic weight loss targets, particularly if there has been a pattern of ‘yo-yo dieting’. Reinforce the health benefits of relatively modest amounts of weight loss, such as a starting goal of 5% of current weight.^3,27

For patients not ready to change their behaviours and lose weight, explain that taking active steps to avoid further weight gain is a worthwhile goal in itself. Most people gain weight over time and so your key priority in these people may be to stabilise weight and prevent further weight gain, rather than weight loss. Regular weighing, for example could help to keep weight stable.²⁷

Ensure patients are given signposts to further information (see below) of how they can begin to make long-term gradual changes to their dietary habits and physical activity. Give them a follow-up appointment at an agreed date (e.g. 3–6 months). Do find out if they are aware of any weight changes in the past year or so as this may be a sign of underlying health problems.