Tackling Obesity in England - National Audit Office

TACKLING OBESITY IN ENGLAND10Examples of local targets for the promotion of physicalactivity and healthy diet set by individual health authoritiesnnnIncrease, by 30% by 2005, the numbers of people who haveregularly walked continuously for a mile at a brisk paceThe percentage of people eating a poor diet according to thecriteria used in the Baseline Survey will be reduced from 29%to 25% by the year 200550 practice nurses will be trained in the dietary component ofHelping People Change by the year 2000c) Managing obesity in generalpractice3.15 General practices are important in the management ofoverweight and obese persons as they are often the firstport-of-call for persons seeking help. They are where mostpeople, obese or not, come into contact with medicalservices 8 , and where there is the potential to tackle issuesof being overweight or obese, possibly as part of aconsultation not initially related to weight problems.Within the primary care setting, general practitioners maysee patients, either directly because of overweight andobesity problems, or because of the associated illnesses,or indeed because of some condition not related at all toexcess weight. Practice nurses, dietitians, health visitorsand school nurses can also play a valuable role inidentifying patients with weight problems and providingadvice and support on weight control and lifestyle changein a more relaxed environment.3.16 The first objective in the management of obesity is toprevent further weight gain 24 . Once weight is stabilised,the second objective is to achieve some level of weightloss. Weight loss goals should be realistic andachievable. For many obese persons, achieving a bodymass index in the ideal range and within a reasonabletime is hard.3.17 This does not imply a counsel of desperation. A weightloss of 5kg (11 lbs) is equivalent to a loss of somesix per cent in body weight for a man or woman ofaverage height with a body mass index of 30, on theboundary between the overweight and obesecategories. This degree of weight loss can reduce backand joint pain, breathlessness, and the frequency ofsleep apnoea, and improve lung function 24 . It may alsoresult in psychological benefits, such as the alleviationof depression and anxiety 25 .3.18 A report by the Royal College of Physicians in 1998 25lists the following potential benefits that can accruefrom a slightly greater weight reduction of 10 per centfrom an initial weight of 100kg in those patients withassociated diseases:nnnnnna substantial fall in systolic and diastolic bloodpressure;a fall of 10% in total cholesterol;a greater than 50% reduction in the risk ofdeveloping diabetes;a 30-40% fall in diabetes related deaths;a 40-50% fall in obesity related cancer deaths;a 20-25% fall in total mortality.3.19 We surveyed a sample of 1,200 general practitionersand 1,200 practice nurses, stratified to be representativeof the range of general practitioners in England, using apostal questionnaire (Appendix 1). We also visited20 general practitioners and 16 practice nurses to carryout face-to-face interviews. The responses showed thatmanagement of obesity within general practice consistsbroadly of three types, depending on the degree ofobesity and the extent of clinical complications. Inascending order of intervention, these are:i) general advice within the surgery, and personaladvice on weight control, diet and physical exerciseaimed at influencing lifestyle;ii) personal advice on weight loss and lifestyle changesupported by drug therapy prescribed by the generalpractitioner; oriii) onward referral by the general practitioner to aweight loss specialist, possibly involving drugtherapy and, in extreme cases, surgery.i) Managing obesity in general practice:general advice, screening and personaladvice3.20 Advice on weight control, diet and physical exerciseprovided by the general practitioner or practice nurse isthe most common approach in primary care. This mayinclude:nadvice on how to modify diet and lifestyle in orderto build in more physical activity;nthe provision of specialised diets and diet plans;nnreferral to exercise programmes, such as throughexercise on prescription (paragraphs 3.35-3.39below); andongoing support, including goal-setting and weightmonitoring.part three21