Helping obese patients lose weight

Over half of women and about two-thirds of men are overweight. One in five adults in England is now clinically obese, with a body mass index (BMI) of more than 30kg/m2, a figure that has trebled in the past 20 years (National Audit Office, 2001).

The condition is linked to a number of chronic diseases (Box 1) and has been implicated in the development of some cancers (Pi-Sunyer, 1993; SIGN, 1996).

Obesity also shortens life expectancy by an average of nine years (NAO, 2001). In economic terms, it is estimated that the NHS spends £0.5 billion each year treating obesity, but the disease actually costs the economy more than £2 billion each year in lost production.

Given these figures, and the fact that the condition is causally linked to diseases currently seen as national priorities, it is not surprising that obesity has had a raised media profile. This not only has a direct impact on demand for obesity services in the NHS, but also places a clear onus on practice nurses and other health professionals to do all they can to tackle it.

What can be done?
There is a considerable evidence to show that improvements in obesity-related morbidity and mortality can be achieved by weight loss of around 5-10% (Goldstein, 1992).

The obesity 'epidemic' is largely the result of changes in lifestyle, principally declining levels of physical activity and rising consumption of high-energy fast foods. Diet and physical activity are, therefore, the prime targets for intervention.

Effective anti-obesity drugs such as sibutramine and orlistat are also now available, but as guidance from the National Institute for Clinical Excellence emphasises, these need to be used as part of a comprehensive weight-management programme (NICE, 2001a; 2001b).

Management strategies
While the traditional GP consultation remains the cornerstone of weight-management services, obesity is a chronic disease that can be managed successfully in nurse-led clinics. Such clinics provide patients with ongoing support and offer the opportunity to bring in other health-care professionals such as dietitians to provide comprehensive dietary advice. In addition, clinics provide the chance to educate patients on the need for regular physical activity.

The advent of primary care trusts offers a great opportunity to take this clinic model further across a number of practices, and to integrate the service with local secondary care services.

Patient selection
The first issue is that of patient selection. Given the social stigma associated with obesity and the widespread nature of the problem, demand is likely to be high.

In an ideal world, weight-management services would be provided to all those in need. Where obesity management services are limited, they should be targeted to those most at risk, that is those with a BMI of 30kg/m2 or more, or those with a BMI of 27kg/m2 who also have accompanying risk factors such as hypertension, dyslipidaemia or Type 2 diabetes.

There is no universally accepted care pathway for managing obesity. However, the most successful approaches take a patient-focused view, beginning with an initial assessment (Box 2) and involve seeing patients on a regular basis over an extended period.

Clearly, most patients wish to lose weight for cosmetic reasons, but many have unrealistic expectations. Weight loss targets should not only be modest and realistic, but should also be staggered: a weight loss of 10% in a year, for example, with a set of progressive targets, such as 5% over three months, and 2.5kg in the first month. This helps to highlight the need for the patient's ongoing commitment to the programme by means of regular monthly appointments for at least a year (Box 3).

Weight maintenance should also be addressed at the start of any weight-management programme and support should be offered long-term. Obesity is a chronic condition and its management should be lifelong.

Lifestyle modification involving changes to diet and physical activity are the cornerstones of obesity treatment. It is essential that a behavioural approach should be integral to any intervention as both diet and physical activity require changes in behaviour to be successful.

The nurse should introduce the notion of keeping a food and activity diary, which the patient should complete as truthfully as possible for at least a week before an appointment. This can often help patients see that they are eating more than they realise.

The exercise diary may similarly be used to prompt discussion of the patient's level of physical activity, as opposed to formal exercise, which many cannot undertake owing to arthritis or breathing difficulties. Patients can be encouraged to walk a little bit more or a little faster each day to increase the number of calories they are burning. Current advice is to aim for at least 30 minutes of brisk walking five days a week. Patients can break this down into two 15-minute walks a day.

Drug therapy
The nurse should stress that not everyone is suitable for drug therapy (sibutramine and orlistat), and that the GP will only prescribe this in accordance with strict assessment and selection criteria, which includes ongoing clinic attendance.

It is important to impress on patients that neither drug will be effective without a continued effort on their part; this means continued adherence to the dietary and activity programme.

The two drugs differ in how they work, and the nurse's observations in the clinic setting may help the GP to prescribe the right one for individual patients. Sibutramine reduces overall energy intake by acting in the brain to prolong the feeling of fullness after a meal, thus reducing the need for snacking. (Chapelot et al, 2000). Orlistat is an intestinal lipase inhibitor that acts in the stomach to reduce fat absorption. Side-effects with sibutramine may include a slight rise in blood pressure in some individuals, while patients taking orlistat may experience mild steatorrhoea.

Therefore, for patients who eat too much through hunger, once-daily sibutramine may be a suitable option, provided they are willing to attend the surgery for regular blood-pressure and pulse-rate monitoring after therapy begins; for those patients able to comply with a low-fat diet, orlistat taken three-times daily with meals may be more suitable.

Both drugs have very good patient support services. 'Change for Life' is a 12-month, behavioural change programme that provides additional support and motivation to patients who have been prescribed Reductil (sibutramine). Through written and audio materials the programme introduces gradual, manageable lifestyle changes, helping patients to change their habits permanently and maintain their new lifestyles.

The Xenical (orlistat) weight-management programme offers a telephone advice service, motivational support to help patients achieve their goal and advice on how to eat more healthily and be more active.

Once a drug has been prescribed, it is important to monitor weight change in the first few months to screen out non-compliers. Treatment with orlistat should be discontinued if patients do not lose 5% of their bodyweight in 12 weeks; those taking sibutramine should have lost at least 2kg after four weeks to continue taking the drug.

Conclusion
Primary care professionals need to understand that obesity is not simply a lifestyle choice; it is a biological response to an individual's environment, but one that can have a profound impact on patients' health. Nurse-led care has the potential to offer tailored health promotion advice and referral to specialists.

It is important that nurses give clear guidance and use evidence-based information to deliver consistent messages (Box 4). Professional organisations such as the Association for the study of Obesity, the National Obesity Forum and Dieticians Working in Obesity Management (DOM UK) are all excellent sources of reliable material.

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