Tackling Obesity in England - National Audit Office

TACKLING OBESITY IN ENGLANDpart three26ii) Managing obesity in general practice:drug therapy3.42 Drug therapy may be used in tandem with a calorierestricteddiet to accelerate weight loss in obesepatients 25 . Health concerns led to the withdrawal in1997 of fenfluramine type anti-obesity drugs, but a newgeneration of anti-obesity drugs is now emerging,beginning with Orlistat, which was licensed in Europein 1998. A necessary condition for prescribing this drugis that the person concerned has been able to loseweight without using the drug, as an indicator ofmotivation and the ability to adhere to a calorierestricteddiet.Many general practitioners are uncertain about theappropriateness and effectiveness of drug therapy3.43 Drug therapy was used by two fifths of generalpractitioners responding to our survey, and by nine ofthe 20 general practitioners we interviewed.3.44 None of those interviewed had had more than a fewpatients taking weight-loss drugs at any one time. Theirattitudes to the use of drug therapy varied. Most felt itwas a useful aid in accelerating weight loss for aminority of patients, but they had some reservations. Inparticular, concerns were expressed about how to assesswhich patients were sufficiently motivated to benefitfrom therapy, and the likelihood of weight regain whenthe drug therapy was terminated.3.45 Since we began our study, the National Institute forClinical Excellence (NICE) has announced that part of itsprogramme in 2000-01 will be to examine the clinicaland cost effectiveness of the anti-obesity drugs, Orlistatand Sibutramine. NICE are expected to issue guidanceon the use of Orlistat in February 2001. This will helpensure that general practitioners are better informedabout the costs and potential benefits of drug therapy fortheir obese patients.iii) Managing obesity in general practice:onward referral3.46 The specialist expertise often necessary in the treatmentof obese patients is normally found outside generalpractice. The six most commonly used options forreferral of patients are shown in Figure 13. The optionmost frequently used was referral to a state-registereddietitian, though long waiting lists were mentioned bysome as a problem.3.47 Not all of these options are available to all NHS patients.About a quarter of general practitioners felt that therange of referral options at their disposal was limited orinadequate. Access to suitable treatments for obesitycan depend on factors such as the prosperity of thepatient and geographical location. For example, patientsreferred to private sector slimming groups do not receivefinancial assistance in meeting the costs of attendance,which may preclude this option for many. And not allgeneral practitioners have local access to a physicianspecialising in weight problems, a suitable communitybasedprogramme, or a surgical consultant ableto advise on the suitability of surgery to achieveweight loss.There is uncertainty about the effectiveness of referraloptions3.48 General practitioners identified a range of factors thatwould assist them in referring patients more efficientlyand effectively, particularly better information aboutproven, effective interventions (Figure 14).Overcoming knowledge constraints in themanagement of obesity3.49 Our survey asked general practitioners and practicenurses what factors might help them in developingfurther their approach in the treatment of overweightand obese patients. Figure 15 shows their most frequentresponses. Action is in hand to address some of theseissues, particularly access to exercise regimes.Obesity protocols are not widely used in primary careand need further development3.50 We asked whether or not national clinical guidelines ora protocol for managing overweight and obese patientswould be a useful tool. Sixty-three per cent of generalpractitioners and 85 per cent of practice nurses believedthat such guidelines would be "useful" or "very useful".However, a minority of the general practitioners andpractice nurses we interviewed suggested that theypreferred more flexibility to recognise individualpatients' needs. This demonstrates that any clinicalguidelines that might be developed need to containsufficient flexibility to allow general practitioners toexercise a degree of judgement over the mostappropriate course of treatment for each patient.3.51 There are two main sets of guidelines currently availablein Britain, and used by some general practitioners inEngland, that are relevant to the management of obesityin general practice. In Scotland, 'Obesity in Scotland:Integrating Prevention with Weight Management', waspublished by the Scottish Intercollegiate GuidelinesNetwork in 1996, and updated in 1997 24 . And in 1998,the Royal College of Physicians of London published'Clinical Management of Overweight and ObesePatients, with particular reference to the use of drugs' 25 .