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At the heart of general practice since 1960

Aspartame 'not guilty' of triggering headache

The obesity crisis and its knock-on effects on other morbidities is one of the biggest health challenges of the 21st century and the appropriate role of GPs in tackling the problem is proving highly controversial. The Government is determined to make obesity a high-profile addition to the next quality and outcomes framework ­ but is it really GPs' responsibility to help individual obese patients lose weight? In this e-mail debate, `

Dr David Haslam argues passionately that GPs must pick up the obesity gauntlet, while Dr Colin Guthrie says his own experience proves that taking on this task is a poisoned chalice.

Meanwhile, on page 62, Professor Colin Waine offers advice to the converted on weight management in

primary care.

Colin,

Obesity is a chronic disease affecting almost a quarter of the population, which leads to a catalogue of co-morbidities including cardiovascular disease, diabetes, around 20 different types of cancer, infertility, mental health disorders, respiratory illness and others.

It is a huge burden to the individual and the economy; the illnesses it leads to sap our time, resources, energy and budget.

There are already so many obese people in the country that epidemics of diabetes and heart disease are almost inevitable, and the only chance we have of avoiding these is by actively treating the underlying obesity.

The new GMS contract is currently under review. The position of obesity in GMS2, in particular, is under scrutiny. If it is to be managed as its status dictates, it is only fair that we, as GPs, are rewarded for doing so.

It is illogical that obesity, which affects almost 25 per cent of the population, has only 0.3 per cent of QOF points designated to it for measuring BMI in diabetics. If it's important in diabetes, why not in CVD and hypertension? All the separate criteria for the metabolic syndrome are represented in the contract apart from the fundamental aetiological factor ­ obesity.

·We know a BMI of 35 leads to around 93 times the risk of diabetes (compared with a normal BMI), and there are said to be 1.5 million undiagnosed diabetics in the UK. It is a simple deduction to work out where the missing ones may be. I always check the fasting blood sugar of my obese patients.

·We know abdominal obesity is a major risk factor for CVD; a simple test to identify those individuals at highest risk is waist circumference. Add in triglycerides, and identification is complete.

·We know the link between obesity and stroke. Get a large cuff, and measure blood pressure on every obese individual who walks into surgery.

I would like to see obesity recording and assessment represented in the new contract and would welcome your views.

All the best

David

David

I agree with everything you have said ­ thus far. We should indeed record the weights of all our adult patients and undertake further investigations where clinically appropriate. I agree that the present contract does not reward us sufficiently for this work and I would welcome changes to remedy this.

Overweight patients should be sensitively and accurately identified, further investigations conducted where indicated and those treated for any medical complications that are revealed.

Now here comes my crunch question and this is probably where we will lock horns ferociously. Do you believe the management of obesity in primary care should include helping the patient to actually lose weight? Should they be provided with a range of possible obesity reduction options by the practice and return for monitoring of their weight over a significant follow-up period?

Should the practice take responsibility for organising this 'treatment'? Should the weight of a patient be something akin to their blood pressure, or their cholesterol level, where an attempt is made to reduce these readings in order to improve their health?

If you believe we should be helping our patients to lose weight then do you believe that this should be reflected in our QOF payments with more money being allocated to practices that can demonstrate they have helped patients lose weight?

When answering this question I would ask you to remember that QOF was established on the principle that it rewards only evidence-based intervention.

Colin Guthrie

Colin,

I'm pleased we agree on identifying, recording and investigating obese patients. It is crucial that the contract rewards the identification of at-risk individuals before co-morbidities develop, rather than merely including obesity management in current disease areas once co-morbid illness already exists.

I wonder if you agree that to avoid unnecessary work, points should be given for keeping a register of patients with BMI >30 (or waist equivalent), rather than assessing the weight of all adults, to prevent us having to weigh Naomi Campbell lookalikes who are clearly at no additional risk whatsoever?

To answer your question, I believe passionately that obesity can and should be actively managed in primary care, including helping patients lose weight ­ but not every obese person.

The sheer number of patients would be overwhelming, and for many commercial slimming organisations, internet sites, books and glossy magazines are the best way.

My interest in obesity started because of my 'discovery' that managing it actively led to dramatic improvements in metabolic profile, especially in diabetics, but also in 'simple' obesity. I'm now of the opinion that attempting to adequately manage diabetes or CVD without addressing the underlying weight problem is futile, and that managing obesity in the general population is synonymous with primary prevention of serious chronic disease, and therefore vital.

I assume we agree that the evidence of obesity leading to serious illness is cast iron, and that the evidence that weight loss improves metabolic parameters including glycaemic control, lipid profile and blood pressure equally so?

We evidently agree that recording and assessment of obese patients is essential, and that weight loss is a good idea. Our sticking point appears to be where and quite possibly how this process occurs.

I would point to the emerging Counterweight study data that shows weight loss of at least 5 per cent in a third of all patients in the trial, using current primary care resources, as showing that it is feasible and practical (www.counterweight.org)

Why wouldn't you treat obesity in primary care?

All the best,

David

David

In 1996 I began to carefully start trying to help some of my overweight patients. My wife, who is my practice partner, was already running weekly women's 'health groups' that focused primarily on trying to help patients lose weight.

This group started in 1986. I started a men's group and used a very full range of therapies which included sports centre exercise referral where patients had a tailored exercise regime with free admission.

We also had a health board-funded dietitian for two years who saw our patients individually and at the weekly groups.

It was a very exciting time for me because almost all the patients showed a significant weight loss and some lost great amounts. Several type 2 diabetics were virtually 'cured' and were able to come off most of their medication.

I still have the picture of me surrounded by my 'ex-diabetics' in the local evening paper photographed outside the sports centre. I was in the London final of a medical innovation competition and gave lectures extolling the virtues of this treatment to my Glasgow colleagues.

Then it all began to fall apart after two years. We had created a vast dependency of patients who needed to be seen from time to time in order to keep their weight down. Few were able to leave our therapeutic nest.

Soon our staff were spending most of their time engaged in this work and it became totally unsustainable. The individual approach to obesity ­ as opposed to a population approach ­ is incredibly time-consuming and unnatural because the practitioner actually becomes the very drug that the patient needs.

I am pleased to hear you are having such success with the Counterweight project and that the 'emerging' evidence you describe is favourable, but this is an individual approach.

I have looked at the methods used and they are what we did and it will fail for the same reason.

I have attended many conferences on obesity and have listened to the world experts and they all say the same thing ­ there is no evidence of any way that we can help patients maintain a weight loss.

Counterweight will follow the same sad pattern for all such weight-loss programmes with the usual 98 per cent recidivism rate as sure as night follows day. General practice does not need or deserve this.

Obesity can be treated ­ but not by us. If we take this poisoned chalice then we will be blamed for our inevitable failure.

Reducing obesity can only be achieved by a population approach and that is the responsibility of Government.

Colin Guthrie

Dear Colin,

You did a fantastic job in inducing weight loss, at a time when there really wasn't the emphasis placed on obesity or encouragement offered to treat it.

It is often a sad fact with weight that 'what goes down must come up' as our patients respond to the toxic environment around them. I often feel that while politicians waste time disagreeing with each other about incoherent policies, that we're dealing with the obesity epidemic one by one.

It still looks like we're nowhere near agreeing!

You have gone from one extreme to the other in your approach to managing this problem in your practice; the fact that you initially embraced treatment in the surgery reveals that you accept the medical aspects of obesity. The fact that you managed to reduce your number of diabetic patients indicates you must have been bloody good at weight management.

The pendulum has swung too far the other way. Your 'ex-diabetics' must, of course, be followed up for life, and their weight is an essential part of that. I wonder what other abnormal metabolic markers you picked up, and what degree of follow-up they get?

Your comment 'we had created a vast dependency of patients who needed to be seen from time to time in order to keep their weight down' is crucial. It suggests to me their weight was actually staying down, and if your dietitian had secured funding, and you had adequate resources to maintain follow-up by group sessions etc, then you would still be appearing in your local paper with grinning ex-diabetics.

We agree that a population model is essential, and we must trust others to bring that about. However, I'm in the red corner, insisting on weight management in surgery, whereas you're in the blue corner, disillusioned with the personal model.

Before we come to blows may I suggest a compromise?

I believe the GMS contract is designed to control risk of chronic disease by rewarding improvements in metabolic risk factors, BP, glucose and lipids. But it is fundamentally flawed because we only get to know our target patients because they've already 'hit the wall' and suffered a cardiovascular event or diabetes.

Those at-risk patients must be selected before they develop frank disease or complications. Therefore obese people must be measured, registered and assessed for those three factors, and we should be rewarded by QOF for doing so. For best practice in obesity management to occur, we would need to induce weight loss, but maybe it's too much too soon to include outcomes in the contract.

How about 30-40 points for 'obesity-related risks' for measuring, registering and assessing obese patients, and offering weight management advice?

David

Dear David

I have no problem with measuring the variables you suggest in the obese and treating their hypertension or diabetes. But remember that about 40 per cent of patients in deprived practices will be obese and so it will be much work and will need adequate payment.

A brief discussion on weight management issues could also be provided but I would strongly resist and resent any attempt to shackle our profession with any QOF payments linked to practices being successful in meeting weight-reduction targets. All the evidence shows this is time-consuming work with very few people maintaining long-term weight reduction.

Incidentally, I did not jettison my weight management patients. Most of them went back to their initial weight after a few years but loved coming to the groups because so many of them suffered that most horrid of all illnesses ­loneliness.

Your obesity forum has featured prominently in recent Pulse articles and you were personally quoted as suggesting that the profession should consider something like 100 QOF points for meeting obesity targets. I am very pleased to see you appear to have greatly moderated your ideas and I expect this was as a result of feedback from your colleagues throughout the UK.

We can only reduce obesity by concentrating on populations. We need healthy environments so that everyone can easily make healthy choices. Children need a ban on junk food advertisng and the opportunity to play outside. Adults need a transport policy that promotes walking and cycling.

The recent all-party parliamentary obesity group made a huge list of recommendations and at the top was a plea for better cycling facilities in our cities. We are shaped by our environment and at present it is sick ­ and it makes us sick. We have the obesogenic environment first described by Egger and Swinburne in their seminal 1995 BMJ paper which simply stated that our environment makes us obese.

This is due to an economic policy that encourages the consumption of energy-dense foods and discourages physical activity with its perverse transport policies and a Government that shows no understanding of children and their needs. Some 60 per cent of the green space used for housing in London in the last 10 years came from the sale of playing fields and play areas.

Our environment is obesogenic because our politicians cater for the wealth of a few over the health of the many. Obesity can only be reversed by a change in Treasury policy.

Colin Guthrie

David Haslam is founder of the UK National Obesity Forum and a GP in Watton-at-Stone, Herts

Colin Guthrie is a GP in Glasgow

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