TACKLING OBESITY IN ENGLANDpart three26ii) Manag<strong>in</strong>g obesity <strong>in</strong> general practice:drug therapy3.42 Drug therapy may be used <strong>in</strong> tandem with a calorierestricteddiet to accelerate weight loss <strong>in</strong> obesepatients 25 . Health concerns led to the withdrawal <strong>in</strong>1997 of fenfluram<strong>in</strong>e type anti-obesity drugs, but a newgeneration of anti-obesity drugs is now emerg<strong>in</strong>g,beg<strong>in</strong>n<strong>in</strong>g with Orlistat, which was licensed <strong>in</strong> Europe<strong>in</strong> 1998. A necessary condition for prescrib<strong>in</strong>g this drugis that the person concerned has been able to loseweight without us<strong>in</strong>g the drug, as an <strong>in</strong>dicator ofmotivation and the ability to adhere to a calorierestricteddiet.Many general practitioners are uncerta<strong>in</strong> about theappropriateness and effectiveness of drug therapy3.43 Drug therapy was used by two fifths of generalpractitioners respond<strong>in</strong>g to our survey, and by n<strong>in</strong>e ofthe 20 general practitioners we <strong>in</strong>terviewed.3.44 None of those <strong>in</strong>terviewed had had more than a fewpatients tak<strong>in</strong>g weight-loss drugs at any one time. Theirattitudes to the use of drug therapy varied. Most felt itwas a useful aid <strong>in</strong> accelerat<strong>in</strong>g weight loss for am<strong>in</strong>ority 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 rega<strong>in</strong> whenthe drug therapy was term<strong>in</strong>ated.3.45 S<strong>in</strong>ce we began our study, the <strong>National</strong> Institute forCl<strong>in</strong>ical Excellence (NICE) has announced that part of itsprogramme <strong>in</strong> 2000-01 will be to exam<strong>in</strong>e the cl<strong>in</strong>icaland cost effectiveness of the anti-obesity drugs, Orlistatand Sibutram<strong>in</strong>e. NICE are expected to issue guidanceon the use of Orlistat <strong>in</strong> February 2001. This will helpensure that general practitioners are better <strong>in</strong>formedabout the costs and potential benefits of drug therapy fortheir obese patients.iii) Manag<strong>in</strong>g obesity <strong>in</strong> general practice:onward referral3.46 The specialist expertise often necessary <strong>in</strong> the treatmentof obese patients is normally found outside generalpractice. The six most commonly used options forreferral of patients are shown <strong>in</strong> Figure 13. The optionmost frequently used was referral to a state-registereddietitian, though long wait<strong>in</strong>g 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 or<strong>in</strong>adequate. Access to suitable treatments for obesitycan depend on factors such as the prosperity of thepatient and geographical location. For example, patientsreferred to private sector slimm<strong>in</strong>g groups do not receivef<strong>in</strong>ancial assistance <strong>in</strong> meet<strong>in</strong>g the costs of attendance,which may preclude this option for many. And not allgeneral practitioners have local access to a physicianspecialis<strong>in</strong>g <strong>in</strong> weight problems, a suitable communitybasedprogramme, or a surgical consultant ableto advise on the suitability of surgery to achieveweight loss.There is uncerta<strong>in</strong>ty about the effectiveness of referraloptions3.48 General practitioners identified a range of factors thatwould assist them <strong>in</strong> referr<strong>in</strong>g patients more efficientlyand effectively, particularly better <strong>in</strong>formation aboutproven, effective <strong>in</strong>terventions (Figure 14).Overcom<strong>in</strong>g knowledge constra<strong>in</strong>ts <strong>in</strong> themanagement of obesity3.49 Our survey asked general practitioners and practicenurses what factors might help them <strong>in</strong> develop<strong>in</strong>gfurther their approach <strong>in</strong> the treatment of overweightand obese patients. Figure 15 shows their most frequentresponses. Action is <strong>in</strong> hand to address some of theseissues, particularly access to exercise regimes.<strong>Obesity</strong> protocols are not widely used <strong>in</strong> primary careand need further development3.50 We asked whether or not national cl<strong>in</strong>ical guidel<strong>in</strong>es ora protocol for manag<strong>in</strong>g overweight and obese patientswould be a useful tool. Sixty-three per cent of generalpractitioners and 85 per cent of practice nurses believedthat such guidel<strong>in</strong>es would be "useful" or "very useful".However, a m<strong>in</strong>ority of the general practitioners andpractice nurses we <strong>in</strong>terviewed suggested that theypreferred more flexibility to recognise <strong>in</strong>dividualpatients' needs. This demonstrates that any cl<strong>in</strong>icalguidel<strong>in</strong>es that might be developed need to conta<strong>in</strong>sufficient flexibility to allow general practitioners toexercise a degree of judgement over the mostappropriate course of treatment for each patient.3.51 There are two ma<strong>in</strong> sets of guidel<strong>in</strong>es currently available<strong>in</strong> Brita<strong>in</strong>, and used by some general practitioners <strong>in</strong><strong>England</strong>, that are relevant to the management of obesity<strong>in</strong> general practice. In Scotland, '<strong>Obesity</strong> <strong>in</strong> Scotland:Integrat<strong>in</strong>g Prevention with Weight Management', waspublished by the Scottish Intercollegiate Guidel<strong>in</strong>esNetwork <strong>in</strong> 1996, and updated <strong>in</strong> 1997 24 . And <strong>in</strong> 1998,the Royal College of Physicians of London published'Cl<strong>in</strong>ical Management of Overweight and ObesePatients, with particular reference to the use of drugs' 25 .
TACKLING OBESITY IN ENGLAND13 Referral options most commonly used by general practitioners0 10 20Percentage of general practitioners30 40 50 6070State-registered dietitiansPrivate sector slimm<strong>in</strong>g organisationPhysicianCommunity-based programme/self -help groupTra<strong>in</strong>ed exercise specialistSurgeonSource: <strong>National</strong> <strong>Audit</strong> <strong>Office</strong> based on responses to postal survey (Appendix 1)14 Factors which general practitioners said would assist them <strong>in</strong> referr<strong>in</strong>g patientsBetter <strong>in</strong>formation about proven, effective <strong>in</strong>terventionsPercentage of general practitioners0 10 20 30 40 50 60Improved access to community-based programmes or self-help groupsBetter <strong>in</strong>formation on available referral optionsGuidel<strong>in</strong>es on the management of overweight/obese patientsImproved access to tra<strong>in</strong>ed exercise specialistImproved access to dietitianBetter tra<strong>in</strong><strong>in</strong>g on the management of overweight/obese patientsImproved access to specialist physicianImproved access to pyschologistAvailability of tra<strong>in</strong>ed practice nurseSource: <strong>National</strong> <strong>Audit</strong> <strong>Office</strong> based on responses to postal survey (Appendix 1)15 Factors which general practitioners and practice nurses said would assist them <strong>in</strong> advis<strong>in</strong>g and treat<strong>in</strong>g patientsPercentage0 10 20 30 4050 60 70 80Guidel<strong>in</strong>es on the management ofoverweight/obese patientsImproved access for general practitionerreferral to exercise regimesAvailability of better patient advicematerials for use by general practitionersand practice nursesBetter tra<strong>in</strong><strong>in</strong>g for general practitionersand practice nurses on the management ofoverweight/obese patientsGeneral PractitionersPractice Nursespart threeSource: <strong>National</strong> <strong>Audit</strong> <strong>Office</strong> based on responses to postal survey (Appendix 1)27
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