 Patients tend not to present to their GP complaining of obesity per se but rather present with a myriad of symptoms and conditions that are caused or aggravated by being obese. These presentations tend to increase with age. We have often managed the situation by treating these conditions with drugs, sometimes to the point of having our patients almost 'rattling'. This places a great burden on our health system for conditions that are to a large extent preventable. In addition patients don't like taking too much medication and compliance with long term preventative medication is poor.
A refreshing approach to dealing with these problems is to tackle the situation from a weight management perspective rather than treating the end result. This does mean gaining new skills in lifestyle management and there seems to be increasing enthusiasm amongst GPs to help their patients lose weight by natural means rather than by use of drugs. For those patients who have already tried scientifically sound weight loss methods using commercial programs or one to one counselling by an appropriately trained health professional, new weight control drugs will come on to the market next year. Time will tell whether these drugs will reduce the use of other drugs that treat the effects of being overweight such as statins, hypoglycaemics and antihypertensives.
Common symptoms of obesity
The commonest presenting symptoms of obesity are shortness of breath on minor exertion, tiredness, depression, difficulty sleeping, low back pain, hip and knee pain. Other less well-known problems that can be related to being overweight are stress incontinence, menstrual disturbances including menorrhagia, oligomenorrhoea and infertility. Sweating is increased through the elevated metabolic rate of being obese and this contributes to skin problems such as oppositional intertrigo.
Medical hazards of obesity
1) Mechanical
Obvious examples of mechanical problems are low back pain and joint pain. Then there is indigestion aggravated by so much abdominal fat. Urinary incontinence is an often undisclosed but embarrassing symptom, particularly for women, and is very common for the obese. Snoring and sleep apnoea have a strong association with abdominal obesity. Venous stasis, cellulitis, oedema of the legs and resulting leg ulcers are commonly associated with obesity and can be the bane of both patients' and GPs' lives. Anaesthetists and surgeons are well aware of the increased risk of surgery for their obese patients. Venous thrombosis is another added risk.
2) Metabolic
It is the metabolic factors that give rise to the main reasons for increased mortality in the obese which has effects by aggravating several of the causal risk factors including high blood pressure and high lipids resulting in atheroma formation. It also aggravates the tendency to thrombosis by elevating coagulation factor V11, and it is the main preventable cause of NIDDM. Being overweight is now increasingly recognised as a major preventable cause of a range of major cancers including colon, breast, endometrial and prostate cancer.
The Framingham study identified overweight as being similar in importance to smoking in predicting premature death with most of the effect being due to accelerated cardiovascular disease. In broad terms having a BMI>30 or waist >102cm in men or >88cm in women means having at least double the mortality risk of people with normal weight (ie BMI 18.5 - 25.)
Quality of life
It is not only the above problems that affect quality of life. There is also the way obese people are treated by others and the low self esteem they endure because of the difficulties to function as well as others in every day life skills. This in turn leads to discrimination, reduced prospects and social isolation, which in turn may lead to depression.
The challenge
From the above it can be seen that for GPs, the return on effort for helping their patients control weight can be paramount - less symptoms, greater life expectancy and better quality of life and self esteem. Each issue of GPSpeak will continue a series of articles on lifestyle management for metabolic fitness and well being to assist GPs to change the emphasis from treating the effects to treating the cause of being overweight or obese.
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