Andrew Binns
Aboriginal Health
Health
Treating the Cause of Obesity, not the Effect
GP Management of Obesity
Health Promotion Through Cycling
Last Modified 2/8/99
by Andrew Binns
Traditionally, GPs have not been too involved in the management of obesity and there are a number of reasons for this.
Firstly, GPs have been trained extensively in the treatment of the long term outcomes of being overweight such as diabetes and heart disease. This training has been dominated by the pharmaceutical industry, which, it could be argued, has a vested interest in not treating obesity. With two new drugs about to be released for treating obesity, this may change. In addition, there has been a widespread view that becoming obese is due to self inflicted sloth and gluttony that is felt to be almost impossible to influence and certainly impossible to cure. Then there is the time issue, where more and more seems to be expected of GPs within the confines of a consultation.
However, more than half our patients are now overweight or obese and the situation is getting worse. This article will attempt to address the barriers to dealing with the problem at the GP level. Bearing in mind 80% of the population of Australia visit their GP in any one year, there are many opportunities to intervene in the weight management of patients. The challenge is knowing what to do in the limited time available and if referral is contemplated, to whom is the question to be addressed. As with smoking, there is no doubt GPs are influential in the advice they give their patients.
Plenty of evidence shows that a realistic and modest 5-10% weight loss is associated with significant health benefits. Even weight maintenance after intervention is better than the inevitable weight gain resulting from doing nothing. A weight loss of 5-10% is associated with useful changes such as 5-10% lowering of blood pressure, 5% reduction in total cholesterol and 10% reduction in triglycerides, 10-15% increase in HDL cholesterol and significant improvement in glycaemic control. Being realistic about weight loss is motivating for both patient and doctor. It is very satisfying for a GP to see a patient improve their cardiovascular and diabetes risk status without additional or even reduced medication.
In addition to weight loss goals there are also some other benefits in metabolic risk profile modification with reduction in serum total cholesterol, serum LDL cholesterol, fasting glucose, fasting insulin and BP
GPs are ideally positioned to intervene with managing obesity, which is the second most common preventible cause of ill-health in Australia after smoking. The time may come when GPs are rewarded through the Practice Incentive Program for achieving certain goals in weight control and risk management for their patients.
How much weight loss is needed for health benefit?
Rather than try to cure obesity by bringing weight down to normal levels and keeping it there, a much more realistic approach is to aim to reduce weight by 5-10% over a few months and thereafter accept a small regain with associated lowering of metabolic rate as the years go by (see graph).
What can GPs do about obesity management?
(1) Use every opportunity possible to intervene.
For example, if an obese patient comes in with a sore throat that can be dealt with quickly use the available consultation time to discuss weight management. They won't be offended if you can offer some positive suggestions. If an overweight patient comes in for a BP check and the reading is say 150/90, talk about the possibility of losing weight rather than increasing the dose of antihypertensive.
(2) Measure all overweight or obese patients.
Measuring weight, height, BMI, waist circumference and BP can be done in 2-3 minutes. A BMI calculator wheel is useful to have on the desk for those who are not computerised. Up to date medical software includes weight management programs that nicely graph weight. This can be a motivating tool for both patient and doctor.
(3) Intervene with nutritional advice.
This involves making different choices in food, choosing lower fat, higher carbohydrate and fibre food. Give practical examples. Resource material is available through Diabetes Australia in the form of flip charts for showing where the fat is in food. Alcohol intake within the WHO guidelines is compatible with weight management, bearing in mind that alcohol is used as a primary fuel whereas fat is readily stored rather than used as a primary source of energy. The taking of alcohol and fat together is particularly fattening and should be discouraged.
(4) Recommend more physical activity.
Use the National Physical Activity Guidelines. Recommending use of pedometers may encourage patients to accumulate enough physical activity for long term maintenance of their weight.
(5) Address some of the behavioural aspects of obesity.
For example, non-hungry eating such as eating due to stress, depression, boredom etc. Other helpful strategies to discuss with patients are the importance of only eating when a bit hungry rather than starving and only eating enough to feel satisfied rather than stuffed full.
(6) Measure fasting lipids and blood sugar levels for everyone and HbA1C for diabetic patients.
(7) Follow up
Follow up the patient on at least a monthly basis and possibly more often in the first few weeks of intervention. Your patients will need long term follow-up and lots of encouragement. Preventing significant weight regain after the initial loss is a major challenge. Don't underestimate your influence in long term success.
(8) Referral
For the more difficult to motivate patients or those patients who are not responding to your intervention over 2-3 months, consideration may be given to referral to a dietitian or to a commercial weight management and lifestyle program such as the GutBuster program. Morbidly obese patients with BMIs greater than 40 may need referral to a specialised obesity clinic. GP follow-up is equally important for all these patients.
New drug treatment
Obesity management at the GP level is about to change radically as two new drugs will soon be available in Australia.
Orlistat
This is a pancreatic lipase inhibitor that prevents the absorption of about 30% of ingested fat that is consequently passesd in the stool producing steatorrhoea. If used with a slightly hypocaloric diet, as well as lifestyle counselling, it can be an effective weight loss drug with minimal side effects. If fat intake is high there will be significant passing of oily stools causing diarrhoea and anal leakage which is obviously a deterrent to such intake.
Sibutramine
This drug is a serotonin as well as an adrenergic re-uptake inhibitor and has the effect of reducing appetite and promoting a feeling of satiety after eating a meal. It is also mildly thermogenic by central effects, which attenuates the usual decline in metabolic rate with weight loss. Since it has no effect on the dopaminergic systems, they are not addictive and have no abuse potential. The side effect profile is good and about 70% of people using it will maintain a 5-10% weight loss over two years. 20-30% of patients will not tolerate it or fail to respond.
Conclusion
GPs can no longer avoid the obesity issue and will need to upskill and become experts in the field just as they have with diabetes and cardiovascular disease. The arrival of two new drugs for treating obesity will not be a reason to just reach for the script pad, but will be a major influence in encouraging GPs to put effort into providing their patients with lifestyle information, or at least referring them to someone who can. It may be that practice nurses could be trained in this area. Resource material for GPs and their patients will be needed and commercial programs will have an important role to play.
Discussion
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