Guidelines on the management of adult obesity and overweight in primary care continued

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 if available, 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

Guidelines on the management of adult obesity and overweight in primary care continued

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 supermarkets and pharmacies
  • 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 their licences and NICE guidance, sibutramine and orlistat are 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 (≥27 for sibutramine) if other obesity related risk factors are present
• 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 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

full guidelines available from…
National Obesity Forum, PO Box 6625, Nottingham NG2 5PA (Tel – 0115 846 2109)
http://www.nationalobesityforum.org.uk

National Obesity Forum. Guidelines on management of adult obesity and overweight in primary care. 2003, updated September 2012

First included: Feb 01, Updated: Feb 03, Feb 04, Oct 05, Jun 07, Oct 12