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Obesity is a major public health problem in Ireland. Currently, 24 per cent of the Irish population are obese (26 per cent of men and 21 per cent of women). It is predicted that this will rise to 50 per cent of men and over 33 per cent of women by 2025. As a result, more and more health professionals will encounter increasing numbers of obese patients dispersed throughout medical and surgical specialties. This highlights that as health professionals, we should strive to have a better understanding of the causes of obesity, its management and the challenges associated with weight loss.
One single factor does not cause obesity; it is much more complex than this. The causes of obesity are multifactorial and are influenced by composite environmental and genetic factors. The causes for each individual will vary; therefore, to aid management of obesity, it is useful to have an understanding of the contributing factors and to help facilitate behaviour change of modifiable factors, if the patient is ready to do so.
When patients fall into the Grade 3 obesity category (BMI ≥40kg/m2), obtaining a weight in the ‘Healthy Weight’ category (BMI 20-25kg/m2) through conservative management, ie, dietary modification and exercise, may not be achievable or realistic. However, sustained, modest weight loss has been shown to confer improvements in metabolic, cardiovascular and psychological health. There is evidence to suggest that 10 per cent loss of body weight can reduce cardiovascular and metabolic risk factors and decrease mortality. For patients in the Grade 3 obesity category, however, a loss of 15-to-20 per cent of body weight may be required for sustained improvements in comorbidities such as diabetes, blood pressure and lipid profile.
Maintenance of 10-to-20 per cent loss of body weight can be very difficult. It requires ongoing practice of new habits and skills, hard work and commitment. Daily food and drink choices can be challenging, as can social events where the environment may be unfamiliar, such as holidays, celebratory and social occasions.
Encouraging maintenance of modest weight loss is important. Preparing patients for setbacks and helping to ensure that they are equipped with both the skills and knowledge to deal with these will help to sustain weight loss.
There is increasing evidence to show that when dietary changes, physical activity and behavioural modification are combined, weight loss outcomes are improved. Traditionally in a consultation, the health professional would impart knowledge and give advice to obese patients. However, employing a patient-centred approach during consultations has been shown to be more effective for weight management. Empowering patients, facilitating behaviour modification and helping patients to develop problem-solving skills are all useful in successfully achieving and maintaining weight loss.
There are several behavioural strategies that contribute to successful weight management, of which self-monitoring seems to be the most predictive of weight loss and maintenance. Self-monitoring encompasses recording food intake, activity and checking weight. Patients who carry out self-monitoring are more successful in losing and maintaining their weight. It is a strategy that requires both time and effort and stimulates reflection on one’s own behaviours. Other practical strategies include planning and preparing shopping lists and meals; altering the home environment, ie, removing high-calorie food and drinks; using smaller plates and bowls; reducing ‘mindless’ eating; and focusing on the meal or snack that is being consumed by avoiding watching the television, using a computer or phone whilst eating.
Drug therapy has a role to play in the management of obesity. Currently, lipase inhibitors and glucagon-like peptide 1 analogues may be used as an adjunct to lifestyle changes. It is important that the patient has a medical assessment prior to commencing pharmacotherapy and that they are informed of the potential side-effects and limitations of drug therapy.
Bariatric surgery should be considered in patients with Grade 3 obesity. Surgical treatment has been shown to be the most effective strategy for the management of morbidly obese individuals and careful screening of patients is required, with multidisciplinary team involvement, including psychological review and assessment. Weight loss ranges from 60-to-80 per cent post-surgery and reaches its maximum at 18 months to two years. Long-term follow-up is required to ensure that adequate nutrition, supplementation and optimal weight loss are achieved.
As highlighted, a multi-faceted approach to weight management is most successful. Our Weight Management Service is a specialist centre managing morbidly obese patients.
The team is comprised of a medical consultant and doctors, a bariatric surgical consultant, a weight management nurse specialist, psychologists, physiotherapists, dietitians and administrative staff. Referrals are accepted from GPs and other healthcare professionals.
The programme runs over a one-year period; each patient receives nine appointments: Six monthly appointments and a further three appointments that are two months apart. During this time, patients receive multidisciplinary care focusing on behavioural change, pharmacotherapy (when appropriate) and assessment of suitability for surgical intervention. Patients are also offered social and group support in exercise, cookery and mindfulness classes.
A patient-centred approach is the main aim, with individualised, tailored care for each patient to promote strategies that fit well with their own lifestyle. This may be comprised of conservative weight management, with or without the addition of medications or surgery.
A 39-year-old man was referred to the Weight Management Service by his GP in 2013. He attended his first clinic appointment in February 2014. He weighed 215kg, with a height of 1.85m, giving a body mass index of 63kg/m2. He recently attended his eighth clinic appointment and has lost 43kg over a one-year period. This means his BMI has dropped by 13kg/m2 and he has lost 20 per cent of his body weight, which confers significant cardiovascular, metabolic and quality of life benefits.
The patient’s approach to weight management was step-wise, setting short-term, measurable goals and making small, sustainable lifestyle changes at regular intervals. Firstly, he developed a regular meal pattern — instead of skipping meals and leaving long gaps between meals, he began eating three meals per day, with two-to-three healthy snacks in between. He started using a smaller plate for all of his meals, which greatly aided portion size reduction.
After his initial clinic appointment, one month later he had lost 0.8kg and was very disappointed. He had been on a two-week holiday and on reflection, identified that both his alcohol and take-away consumption had significantly increased and this could explain the slow rate of weight loss. He was frustrated with this setback. The ‘all-or-nothing’ approach was highlighted at this point and strategies to cope with occasions such as holidays/birthdays/celebrations were explored — how to plan and prepare for events in the future to prevent a significant change in lifestyle habits. He set a goal of reducing calorie content of snacks for a month. He also began self-monitoring, ie, using a mobile phone application to count his daily calories for weight loss. This increased his awareness and enhanced mindfulness around eating and he lost 14.1kg over the next month.
At the next appointment, he highlighted the difficulties with his long working hours and the impact that this can have on food choices, such as making poorer choices if he was tired. He worked in an environment where there was a lot of temptation in relation to food; identifying this as a challenge and having healthy meals and snacks prepared was paramount in this case. His family were very supportive of his weight-loss strategies and having a weight-friendly environment in the home had been very helpful with achieving his goals.
Walking two miles daily with his dog became another lifestyle change for the patient and aided his continued successful weight loss. By his fourth clinic appointment, he had lost 24kg. During another two-week holiday later in the year, he gained 1.4kg. He felt this was attributable to significantly less activity compared to what he was doing at home. He successfully got back on track after his holiday and continued to employ his well-established weight management strategies.
Currently, this patient has lost 20 per cent of his body weight, conservatively, through lifestyle modification over the past year. He reports significant improvements in his quality of life in terms of energy and sociability. He can now walk six miles most days of the week with his dog. He has faced challenges, such as obesogenic environments on holidays, in work, at celebrations and events and has become equipped with tools to manage these situations to maintain weight-management strategies. He is commencing glucagon-like peptide 1 analogue and after multidisciplinary team review and assessment, has been placed on a waiting list for bariatric surgery.
In the interim, he will be encouraged to continue his weight management strategies and to set small, measurable, achievable, realistic goals and regular intervals for continued success.
References and reading sources
- Colquitt et al, Surgery for Weight Loss in Adults (Review). Cochrane Database, Systematic Review, 2014, Issue 8.
- Dietz, William H et al. Management of obesity: Improvement of healthcare training and systems for prevention and care. Lancet 2015, available from http://dx.doi.org/10.1016/S0140-6736(14)61748-7, accessed 14 March, 2015.
- Tackling obesities: Future choices — project report, 2nd Edition (online). Foresight. Available from www.foresight.gov.uk, accessed 13 March 2015.
- Ma et al. Association between eating patterns and obesity in a free-living US adult population. American Journal of Epidemiology, 2003; 158: 85-92.
- National Adult Nutrition Survey. Report on food and nutrient intakes, physical measurements, physical activity patterns and food choice motives, 2011.
- National Institute for Health and Clinical Excellence. Obesity – guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children, 2006.
- Position of the American Dietetic Association — Weight Management. Journal of the American Dietetic Association, 2009; 9: 330-346.
- Report of the National Taskforce on Obesity: Obesity — the policy challenges, 2005.
- Scottish Intercollegiate Guidelines Network. Management of Obesity: A National Clinical Guideline, 2010.
- World Health Organisation. Obesity: Preventing and managing the global epidemic. Working Group on Obesity, Geneva, 1998.