Obesity: time for a new approach in general medicine? Part 1

Obesity is a complex problem with huge costs for the individual, the NHS and society. As the problem worsens, it may be time to consider a new approach to combating the disease. One option would be a population health approach to general practice. Ishraga Awad, Sarah Cuschieri, Michelle A Miller and Claire Beynon from Faculty of Public Health Special Interest Group for Primary Care and Public Health explain more in the first two articles on the matter.

The starting point in treating obesity is understanding that it is NOT a lifestyle choice.

The World Health Organization defines obesity as “a complex chronic disease in which abnormal/excessive body fat (adiposity) impairs health, increases the risk of long-term medical complications and shortens lifespan”. Seeing it that way, rather than as a choice, is an important paradigm shift. And it’s one that has a significant impact on the approach when it comes to tackling it at the individual and population level.

Obesity is an extremely complex problem. It is influenced by intrinsic and extrinsic factors, including genetic/epigenetic, biological, behavioral and mental health.

Extrinsic factors include economic, social, cultural and market determinants that can be overwhelming and restrict or completely remove individuals’ choice and control. It has a direct and indirect impact on health inequalities. Obesity is a cause and an effect of disease, poverty, low education and poor employment opportunities.

Then there is the stigma. The role of stigma in perpetuating the disease is well documented. Stigma is a barrier to effective healthcare as it exists among healthcare workers and influences their response to patients. And internalized stigma compounds the problem. Feelings of guilt and shame, poor body image, low self-esteem, and poor mental well-being leading to anxiety and depression are often a direct cause of poor health behavior. Patients rarely come to see their GP to complain about their weight.

Why should we worry?

The costs at the societal level are enormous. The government estimates them at £6.1 billion for the NHS and £27 billion for society at large (1).

At the individual level, obesity affects every organ system in the body. It leads to metabolic problems, such as non-alcoholic fatty liver disease (NAFLD), CVS disease and type 2 diabetes. It also affects psychological health – low self-esteem, depression and anxiety – and neurological problems, such as chronic pain and neuropathies. And this can lead to mechanical musculoskeletal complications and disability. Obesity reduces quality of life and life expectancy – a patient with a BMI of 40+ has a 50% chance of dying before the age of 70.

During the pandemic, obese people were reported to have a three times higher risk of suffering from serious illness and requiring hospitalization due to COVID-19. And the effects didn’t stop there. The pandemic has contributed to the increased prevalence of obesity, especially among children. Stay-at-home mandates and social isolation, along with increased anxiety and stress, have taken their toll. The result was increased comfort in eating and snacking as well as a reduction in physical activity.

Overweight and obesity affect 60% of adults and one in three children (‎29% of boys and 27% of girls)‎ in the WHO European Region. UK figures are similar at 63% of adults (see Table 1 below).

How can we handle it?

The WHO Report on Obesity in the European Region focuses on managing obesity across the lifespan and tackling obesogenic environments. However, at the primary care level, we need clinical pathways that can easily identify obese or overweight patients and provide appropriate and sensitive consultations that lead to effective management interventions.

Clinical approaches should be used with multicomponent behavioral interventions to achieve optimal effectiveness. Lifestyle support through health coaching and lifestyle medicine approaches is an essential complement to other interventions for long-term weight management.

Key management interventions include sleep examination (see box). Sleep quality and duration are key factors contributing to weight gain, the inability to lose weight or maintain weight loss in adults and children.

Another critical intervention is clinical psychology. Several non-normative eating behaviors are recognized in obese patients. Examples include emotional eating, binge eating, food addiction and cravings, snacking and grazing. These disorders can affect patients after bariatric surgery, resulting in poor weight loss or weight regain.

Management interventions

Clinical nutrition should also be included in dietary interventions that promote healthy eating, which is essential for the prevention and management of childhood obesity. Additionally, dietitians are essential in helping adults maintain long-term weight loss.

Physical activity is another intervention to consider. This is particularly important in the prevention/management of childhood obesity.

And then there is drug therapy. Pharmacotherapy is indicated in addition to diet and physical activity for chronic weight management in obesity (BMI > 30 kg/m2) and overweight (BMI > 27 kg/m2 or > 28 kg/ m2 with comorbidity for Orlistat). NICE guideline CG189 – updated September 2022 – recommends liraglutide for patients referred to level 3 services. However, it is not available by prescription in primary care.

A systematic review and meta-analysis (n=29,018) comparing weight loss and adverse events among drug treatments for obesity in overweight and obese adults found that compared to placebo, orlistat , liraglutide and other non-UK approved treatments (lorcaserin, naltrexone-bupropion and phentermine-topiramate) were all associated with at least 5% weight loss at 52 weeks. Liraglutide and phentermine-topiramate were associated with the highest odds of achieving at least 5% weight loss. [2]

Finally, there are endoscopic procedures and bariatric/metabolic surgery. Surgery remains the most effective obesity treatment, and benefits have been reported for type 1 diabetes, type 2 diabetes, and NASH/NAFLD. With respect to this procedure, the role of primary care is primarily timely referral and post-operative follow-up.

A population health approach

A population health approach considers the broader determinants of health. That is to say the effect of the obesogenic environment, the impact of inequalities, the role of working in partnership – health in all policies and community resources.

Fundamentally, a population health approach must consider primary care commissioning, contracting, and broader health system resources. It encompasses the care of patients in the context of living and working conditions and their communities. It also takes into account the wider social, cultural and environmental factors that determine these conditions (see below).

Of course, many of these factors are beyond the direct influence of general practice, except through effective multi-agency partnerships. But that’s not to say GPs can’t take a population health approach to tackling obesity. The second part of this short series will explain how they can go about it.

The references:

1. NICE Guide CG189, updated on 22/10/2002
2. Khera, R., Murad, MH, Chandar, AK et al. (2016) Association of pharmacological treatments of obesity with weight loss and adverse events: systematic review and meta-analysis. JAMA 315(22), 2424-2434.
3. Cappuccio FP, et al. Meta-analysis of short sleep duration and obesity in children and adults. Sleep. 2008 May;31(5):619-26; Miller MA et al. Sleep duration and incidence of obesity in infants, children and adolescents: a systematic review and meta-analysis of prospective studies. Sleep. 2018 April;41(4)
4. Spiegel K et al. Reduced sleep in healthy young men is associated with decreased leptin levels, elevated ghrelin levels, and increased hunger and appetite. Ann Intern Med. 2004;141(11):846-850. 55
5. Cappuccio, FP and Miller, MA (2011). Is prolonged lack of sleep associated with obesity? BMJ: British Medical Journal, 342. (Editorial)

By Dr Ishraga Awad, General Practitioner and Public Health Specialist, Dr Sarah Cuschieri MD, PhD (Public Health), Dr Michelle A Miller, Associate Professor of Biochemical Medicine, Division of Health Sciences Warwick Medical School, Warwick University, Claire Beynon, Deputy Director of Public Health Health, Cardiff and Vale Local Public Health Team; Cardiff and Vale University Health Council.

This article first appeared on our sister title, Health Care Manager