Obesity is a complex issue with enormous costs to the individual, the NHS and society. A population health approach in general practice could help. Ishraga Awad, Sarah Cuschieri, Michelle A Miller, and Claire Beynon from the Faculty of Public Health Special Interest Group for Primary Care and Public Health explain more in the first two articles on the issue.
The starting point in dealing with obesity is understanding that it is NOT a lifestyle choice.
The World Health Organisation defines obesity as “a complex chronic disease in which abnormal/ excess body fat (adiposity) impairs health, increases the risk of long-term medical complications, and reduces lifespan”. Seeing it this way, rather than as a choice, is an important paradigm shift. And it’s one that significantly impacts the approach when it comes to tackling it at an individual and population level.
Obesity is a hugely complex problem. It is influenced by intrinsic and extrinsic factors, including genetic/ epigenetic, biological, behavioural and mental health.
Extrinsic factors include economic, social, cultural and commercial determinants that can be overwhelming and restrict or entirely remove choice and control from individuals. It impacts health inequalities both directly and indirectly. Obesity is a cause and effect of illness, poverty, poor educational attainment, and poor employment opportunities.
Then there is stigma. The role of stigma in perpetuating the condition is well documented. Stigma is a barrier to effective healthcare as it exists among healthcare workers and influences their response to patients. And internalised stigma worsens the problem. Feelings of guilt and shame, poor body image, low self-esteem and poor mental wellbeing leading to anxiety and depression are often a direct cause of poor health-seeking behaviour. Patients rarely come to their GP to complain about their weight.
Why should we worry?
The costs at societal level are huge. The Government estimates these at £6.1 billion to the NHS and £27 billion to the wider society (1).
At an 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 issues, such as chronic pain and neuropathies. And it can cause mechanical musculoskeletal complications and disability. Obesity reduces the quality of life and life expectancy – a patient with a BMI of 40+ has a 50% chance of dying before the age of 70 years.
During the pandemic, people with obesity were reported to have a three-fold increased risk of experiencing severe illness and requiring hospitalisation with COVID-19. And the effects did not end there. The pandemic has contributed to rising obesity prevalence, especially among children. The mandates for staying at home and social isolation, alongside increased anxiety and stress, took a toll. The result was increased comfort eating and snacking as well as a reduction in physical activity.
Being overweight and obese affects 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 manage it?
The WHO Report on Obesity in the European Region focuses on managing obesity throughout life and tackling obesogenic environments. However, at primary care level, we need clinical pathways that are capable of readily identifying patients living with obesity/overweight and providing appropriate, sensitive consultations that lead to effective management interventions.
Clinical approaches should be used with multicomponent behavioural interventions to achieve optimal effectiveness. Lifestyle support through health coaching and lifestyle medicine approaches is an essential adjunct to other interventions for long-term weight management.
Key management interventions include looking at sleep (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 behaviours are recognised in obese patients. Examples include emotional eating, binge eating, food addiction and cravings, nibbling and grazing. These disorders can affect patients post-bariatric surgery, leading to poor weight loss or weight regain.
Management interventions
Clinical nutrition should also be included with dietary interventions promoting healthy eating, which is essential in preventing and managing childhood obesity. In addition, dieticians are crucial in supporting adults to maintain long-term weight loss.
Physical activity is another intervention to consider. This is of particular importance in preventing/ managing childhood obesity.
And then there is pharmacotherapy. Pharmacotherapy is indicated as an adjunct to diet and physical activity for chronic weight management in obesity (BMI>30kg/m2) and overweight (BMI>27kg/m2 or >28kg/m2 with co-morbidity for Orlistat). NICE guideline CG189 – updated September 2022 – recommends Liraglutide for patients referred to Tier 3 services. However, it is not available for prescription in primary care.
A systematic review and meta-analysis (n = 29,018) that compared weight loss and adverse events among drug treatments for obesity in overweight and obese adults found that compared with placebo, orlistat, liraglutide, and other treatments not licensed for use in the UK (lorcaserin, naltrexone-bupropion, and phentermine-topiramate) were all associated with achieving 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, Type 2 DM and NASH/NAFLD. Regarding this intervention, primary care’s role is mainly a timely referral and post-surgery follow-up.
A population health approach
A population health approach takes into consideration the broader determinants of health. That is, the effect of the obesogenic environment, the impact of inequalities, the role of partnership working – health in all policies, and community resources.
Crucially, a population health approach must consider primary care commissioning, contracting and wider health system resources. It encompasses managing patients within the context of living and working conditions and their communities. It also considers the broader social, cultural and environmental factors that determine these conditions (see below).
Of course, many of these factors are outside the direct influence of general practice except within effective multi-agency partnerships. But that is not to say that GPs cannot take a population health approach to tackle obesity. The second part of this short series will explain how they can go about it.
Sleep and Obesity
There is increasing evidence to support a link between short sleep and the development of obesity both in children and adults. [3]
Short sleep appears to influence various hormonal responses, which may lead to dysregulation of appetite control, affecting both hunger and satiety. These include lower leptin and higher ghrelin levels [4].
Sleep support is one of the core aspects of a lifestyle medicine approach to health, together with relaxation/ stress relief, nutrition, physical activity and reducing substance misuse (tobacco and alcohol mainly).
Obesity is a risk factor for developing the sleep disorder Obstructive Sleep Apnoea (OSA), which has an associated increased risk of CVD.
If untreated, OSA leads to disrupted sleep and sleep loss, which may lead to metabolic and hormonal changes that increase appetite and weight gain. This can result in a vicious bidirectional pathway. [5]
By Dr Ishraga Awad, GP and Public Health Specialist, Dr Sarah Cuschieri MD, PhD (Public Health), Dr Michelle A Miller, Associate Professor Biochemical Medicine, Division of Health Sciences Warwick Medical School, Warwick University, Claire Beynon, Deputy Director of Public Health, Cardiff and Vale Local Public Health Team; Cardiff and Vale University Health Board.
References:
- NICE Guidance CG189, updated 22/10/2002
- Khera, R., Murad, M.H., Chandar, A.K. et al. (2016) Association of Pharmacological Treatments for Obesity With Weight Loss and Adverse Events: A Systematic Review and Meta-analysis. JAMA 315(22), 2424-2434.
- 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 Apr;41(4)
- Spiegel K et al. Sleep curtailment 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
- Cappuccio, F.P., & Miller, M.A. (2011). Is prolonged lack of sleep associated with obesity? BMJ: British Medical Journal, 342. (Editorial)
