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Last-minute catch-up on quality points

Patient's obesity hasn't been cured by 'miracle pill'

Three GPs share their approach to a practice problem

Case history

Mrs MacKinnon is 48 with a BMI of 47, a family history of diabetes and a blood pressure of 150/90mmHg. She has been on an SSRI for over a year, has tried all the diets in a

10-year obesity career, and saw your partner a couple of months ago because a friend had recommended taking orlistat.

Your partner told her to switch to a low-fat diet. She managed to lose 6lb in the first month so she was duly given a month's prescription for orlistat.

She has come back to you for another prescription today and is distraught to find that she hasn't lost any more weight.

Dr Frances Wedgwood

'The last thing she needs right now is another obesity lecture'

This could be a long and tricky consultation because there's a lot to cover. The first challenge is to avoid thinking 'heartsink' and instead to acknowledge her crashing disappointment. The last thing she needs right now is another obesity lecture. Since I need to bring her back in a few weeks to check her BP, and her fasting glucose and thyroid function tests for that matter, I'll save the lecture for now.

I wonder how much orlistat she took. The side-effects might have proved too much. And the product information leaflet is pretty scary; the thought of oily leakage and faecal urgency may have frightened her off popping a pill beyond a safe radius of her own loo. Plus the advice to omit a dose if you miss a meal or if it has no fat content is confusing if you're eating erratically as dieters are wont to do.

But the NICE guidelines are pretty clear ­ 5 per cent weight loss at three months or no prescription.

Now I know I'm not the first to go there, but what's preventing her from losing weight? Is the key issue her low mood? Do her family support her? Maybe she feels too big and uncomfortable to exercise. Or is it embarrassment, joint pains or lack of access that stop her?

Hopefully we can negotiate some realistic targets for the coming weeks without her feeling too overwhelmed. Ideas such as a food diary or seeing the dietitian, or recruiting the whole family, or exercising with a friend are worth thrashing out. Or, on a different tack, counselling, increasing the dose of the SSRI or another antidepressant.

But, at the risk of sounding too Zen, or maybe just too MRCGP, she has to choose her options here. Only she can make those changes.

Frances Wedgwood finished her VTS in September 2003, and now works on the flexible career scheme in Norbury, south London

Dr Mark Wallace

'I wouldn't be surprised if she'd pinned all hopes on this pill'

I am dubious of the merits of orlistat, given that it acts really as a pharmacological way of ensuring a low-fat metabolic intake irrespective of diet. Like many of my colleagues I view it as unnecessary if the patient adheres to a rigid low-fat diet. It also creates an external locus of control ­ in other words, it disempowers the patient.

NICE guidelines state that once started on treatment the patient has three months to effect a 5 per cent reduction in weight, and so in principle I wouldn't be averse to prescribing more orlistat. But I'd want to explore why Mrs MacKinnon hasn't maintained her initial encouraging progress. Indeed, perhaps she'd do better without orlistat given her progress so far.

Her distraught reaction seems extreme ­ after all, she hasn't gained the weight she originally lost ­ and reinforces my suspicion that she must have many issues with her gross obesity. I wouldn't be surprised if she'd pinned all her hopes on this 'magic pill' and she may have relaxed the dietary regime that had served her well in the first month.

She is on an SSRI already, which has an anorexic effect. Is her mood adequately controlled and, if not, is it worth considering increasing the dose for the effects on both mood and appetite? This decision would be best left to her usual doctor. She has probably been referred to a dietitian before, but it may be worth

re-referring given her current motivation.

Also, if she agreed, I might suggest she joins a weight-reducing group, and I'd offer her 'exercise on prescription' because she will need support and guidance if she starts an exercise programme.

As with any patient who seems motivated to make a lifestyle change, I'd want to ensure we capitalised on her current frame of mind. If she sees orlistat as an important adjunct to her own measures, then I'd be willing to prescribe a further two months' of the drug with ongoing support and monitoring. I'd then reassess her after a total of three months' treatment.

Mark Wallace completed the VTS in 1996 ­ he is a GP in Oxford and an undergraduate GP tutor at the University of Oxford

Dr Melanie Wynne-Jones

'I would emphasise the need to develop long-term healthy eating and exercise habits'

Mrs MacKinnon isn't happy and neither am I. As I haven't seen her before I will review the history; how she tells the story may give me clues to possible helps and hindrances for change.

Why and how did she become obese, what diets and clubs has she tried and why did they fail? If she comfort eats, does she also smoke and drink alcohol? Are there any barriers to her taking exercise? What went wrong this time? Did she stick to the low-fat diet?

Does she understand the health implications of obesity? It would be negligent not to spell them out, but she may not yet be motivated to change. Mental state may be the most significant factor and she may benefit from seeing a psychiatrist or clinical psychologist.

Referring her to a dietitian may be helpful, but she probably knows more about dieting than I do. I would emphasise the need to develop long-term healthy eating and exercise habits rather than looking for the magic diet. Her BP currently rules out sibutramine, but I might be willing to prescribe another month's orlistat if I thought she could cut her fat intake. I would warn her that NICE guidelines would prevent me from prescribing any more if she doesn't lose weight.

I would probably see her once more myself, but would suggest she then sees the health care assistant for weighing, with the stick that no weight loss means no more appointments or prescriptions. I am not unsympathetic, but this may act as an incentive, and the practice can't afford to invest time in people who are not yet ready to change.

Melanie Wynne-Jones has been a GP for 20 years and is a GP trainer and appraiser in Marple, Cheshire

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