Guidelines on the Management of Adult Obesity and Overweight in Primary Care

Overview

Obesity and overweight can be managed in primary care by a motivated, well-informed multidisciplinary team. The aim of treatment is to achieve and maintain weight loss by promoting sustainable changes in lifestyle.

Patient Selection

• Most patients attending diabetic or cardiovascular clinics will automatically be candidates for weight management. Other patients may be picked up by practice audit, opportunistic screening or self-referral. Posters and leaflets should be available in the surgery and community for the education of patients

Treatment Groups

• Treatment or advice should be offered to:
  • patients with body mass index (BMI) >=30
  • patients with BMI >=28 with comorbidities, e.g. COPD, coronary heart disease and diabetes
  • patients with any degree of overweight coinciding with diabetes, other severe risk factors or serious disease
  • patients who self-refer, where appropriate
• Parents of families with more than one obese or overweight member may need special consideration and more intensive support
• Prevention advice should be offered to high-risk individuals e.g. those with a family history of obesity, smokers, people with learning disabilities, low income groups

History

• This should include:
  • personal medical history
  • family and social history
  • history of dieting
  • readiness to change and barriers to change
  • current diet and level of activity

Investigations

• Purpose:
  • to isolate any medical pathology
  • to act as a baseline for future measurements
  • to exclude any secondary conditions or comorbidities
  • to reassure patients that there is no reason why they cannot lose weight
• Investigations to carry out:
  • height and weight
  • BMI ( >=25 overweight, >=30 clinically obese)
  • waist circumference (>102 cm for men or >88 cm for women leads to substantially increased health risk)
  • blood pressure
  • urinalysis
  • microalbuminuria screen
  • blood tests if appropriate: consider U and Es,TFTs, LFTs, fasting blood glucose, fasting lipids, hormone profile including sex hormones and cortisol
  • other tests should be carried out as dictated by comorbidities, e.g. CXR, ECG, glucose tolerance test, HbA_1c, creatinine clearance
• BMI is an indirect measure of fatness and can be unreliable, e.g. in children and athletes. Bioelectrical impedance analysis can be used to measure body fat and lean tissue mass; it is reliable and accurate, and can be motivational in patients who become more active and improve their body composition. It is assessed with an inexpensive stand-on body composition analyser

Primary Care Teamwork

• After initial assessment, management should involve as many members of the primary care team as possible according to availability, e.g. doctor, practice nurse, dietician, counsellor to provide support and advice about weight loss and its long-term maintenance
• Information should be made available on local facilities for exercise and physical activity, relevant support groups and weight management groups
• Each member of the team should give consistent advice, and have a positive approach

Treatment

• Parents and families:
  • it is important to give special consideration to situations where parents and other family members are obese or overweight. Parents are important role models for their children, but a child may be the catalyst for change in the whole family. Successful interventions involve the whole family, and the children/adolescents and family should be willing and motivated to make lifestyle changes
• Weight maintenance should be addressed at the start of any weight management programme and support for any weight loss achieved should be offered on a long term basis. Obesity is a chronic condition and its management should be lifelong

Goals

• Aim for 10% weight loss in 3 months to achieve significant health benefits
  • 5–10% has been shown to produce measurable health outcomes
• Any weight loss should be encouraged and for some, weight maintenance, rather than weight gain, may be a realistic goal

First Line Treatment

• The aim is to achieve a 500 kcal deficit of energy requirements through changes in diet and physical activity
• Support and encouragement, e.g. weight management clinics either within primary care or commercially run
  • targets, treatments and expectations should be agreed with patients, e.g. 0.5kg per week or 10% maintained weight loss, rather than 'ideal weight'
  • advise about co-existing risk factors e.g.alcohol, smoking, hyperlipidaemias
  • regular follow-up appointments should be made to help maintain weight loss, monthly initially, then 1-3 monthly for at least 1 year
• Encourage permanent sustainable lifestyle changes:
  • some activity every day
  • less television and computer games
  • a less sedentary lifestyle
  • more exercise:
    • 30-40 minutes sustained exercise, e.g. brisk walking, swimming or cycling, at least 5 days per week
  • more exercise during daily routine:
    • use stairs instead of lifts
    • walk to work, or park the car further away from workplace
    • take a walk during lunch break
    • gardening, washing the car, activities around the home
  • activity as a whole family, e.g. walks or trips to the park for relaxation

Dietary Changes

• Establish regular meals, including breakfast, and encourage healthy eating for long-term weight management
• Reduce dietary fat:
  • avoid fried food
  • grill, boil, or bake
  • buy lean cuts of meat
  • avoid crisps, pies, cakes, biscuits
  • use semi-skimmed milk and low fat spreads
• Encourage healthy snacks, e.g. fruit as an alternative to sweets, chocolates, or crisps
• Provide advice to patients about food labelling
• Encourage self-monitoring, i.e. food diaries to enable patient to establish areas for change
  • suggested changes need to be tailored to the individual
  • giving standard diet sheets is rarely effective
• Use locally approved advice sheets to ensure consistency of messages
  • contact local dietetic departments for guidance
• Other dietary options
  • meal replacements provide a suitable option for some patients. These are structured diet plans normally involving the consumption of two meal replacement drinks per day, plus a self prepared evening meal, fruit and vegetables, totalling approximately 1200-1400kcal. They are available from pharmacies and supermarkets
  • very low calorie diets (diets containing less than 800 kcal/day) should only be used under close medical and dietetic supervision
• Success of first-line treatment is gauged after 3–6 months by reduction of BMI, weight reduction (e.g. 5–10%) or waist reduction (5–10 cm), improvement of symptoms, or reduced markers of comorbidity (e.g. exercise tolerance or blood sugar)
  • if these criteria are not achieved, second-line treatment should be considered

Second Line: Drug Treatment

• The only treatment licensed for obesity is orlistat. Sibutramine and rimonabant have recently been withdrawn
• The pancreatic lipase inhibitor orlistat may be used in conjunction with a low fat diet to achieve more rapid and greater weight loss. Patients must demonstrate a 5% reduction in weight in 12 weeks to comply with licensing and NICE guidance. Orlistat is not absorbed from the gut, and is therefore free from systemic side-effects; however patients eating inappropriate high amounts of dietary fat may experience oily bowel motions, flatulence or leakage
• According to the licence and NICE guidance, orlistat is indicated for the promotion of weight loss as an adjunctive therapy within a weight management programme for patients with nutritional obesity and a BMI of ≥30, or ≥28 if other obesity related risk factors are present
• In considering overweight and obese patients with diabetes, agents such as DPP-4 inhibitors, GLP-1 mimetics and SGLT-2 inhibitors are more weight-friendly options than insulin and sulphonylureas

Other Therapies

• Behavioural therapy or alternative treatments such as acupuncture and hypnotherapy
• Referral to hospital obesity clinic when insufficient weight loss achieved, particularly when BMI is >40, or >35 with comorbidities, or in presence of uncontrolled complications
• Bariatric surgery can be extremely successful, but is only indicated in the severely obese; someone who is >100% above their ideal weight, has a BMI >40 or is at immediate risk of serious medical complications
  • an increasingly common procedure is the laparoscopic gastric band. By this method the functional capacity of the stomach is permanently reduced by the partitioning off of a small segment of the body of the stomach, in order to reduce food intake
  • older methods, including the 'Roux-en-Y' technique, surgically bypass the stomach, thereby combining malabsorption of food with restriction of the capacity of the stomach