Obesity module 1: management in primary care

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How and when to raise the issue

Obesity clinicPrejudices 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

• The opener

– Always consider whether your patient’s weight may be relevant both to future health and to the presenting complaint, and if he/she would benefit from active management.

– Start with asking “How do you feel about your weight?” or “ Do you keep an eye on your weight?”. This avoids casting a judgement and gives the patient the opportunity to join the conversation if they wish without being defensive. You might be surprised that the patient has already lost some weight – if so, give encouragement. Follow this with “Is it something you would like to discuss further or get some (more) support with?”

– Acknowledge the difficulties in changing weight. Explore what steps the patient may have tried already. What helped? What didn’t? Emphasise the benefits of long-term lifestyle improvement over short-term ‘dieting’. Physical activity will help weight maintenance, but weight loss will require dietary management too.

– Check whether weight management is a priority for the patient right now. Would they gain more health benefit from quitting smoking, perhaps? Should any mental health aspects be addressed first?

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

Weight measurementA 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.