The Obesity Problem
Did you know over a quarter of people in the UK are obese? About 2/3 are overweight. In other words, we have an obesity problem in the UK. Obesity is big news in healthcare and is the primary cause of type 2 diabetes.
Obesity is directly linked to a number of different illnesses including type 2 diabetes, fatty liver disease, hypertension, gallstones gastro-oesophageal reflex disease (GORD), as well as psychological and psychiatric morbidities (NICE, 2014).
Patients often get a bee in their bonnet when told they are obese. I probably would too, it’s not very nice to hear. Most people see obesity as derogatory term. However, this is not it’s intention.
Body Mass Index
In practice obesity is a medical term describing anyone who’s body mass index (BMI) is over 30kg/m2 (lower cut offs exist in some Asian and African populations). So try not to be too offended – as hard as that may be.
BMI is where you take your weight in kg and divide this by your height in meters twice i.e. 80kg/1.72m/1.72m.
BMI isn’t perfect. People are different shapes, sizes and ages. Some people have a large muscle mass skewing the result because they are heavy for their height.
However, what BMI is good for is a quick eyeball of where the patients weight is for their height. In other words, are they under, normal or overweight? This is taken alongside obvious measures such as looking at the patient and seeing whether they are an obvious body builder.
Problem is, most patients aren’t body builders and so BMI usually reflects quite accurately.
You’d likely be surprised how little extra weight you need to carry before tipping into the obese category. I can think of several people I know personally who would likely be obese despite not appearing grossly overweight.
One big challenge I face is recognition of obesity. Commonly patients say things like I know I carry too much weight but I wouldn’t say I’m obese. Another one is not wanting to lose ‘too much weight’ because they would be rake thin.
Lets address this. First, remember obesity is a medical term not something you call someone on a whim. It can be measured and classified.
Second, normal weight is anywhere between a BMI of 18.5-24.9kg/2. Therefore, BMI should be reflected as a range not a single figure. In a person standing at 1.72m or around 5 foot 8, this equates to a weight range of 54.7kg – 73.6kg. Quite a range. Admittedly, 54.7kg for a man who is 5 foot 8 is pushing it and they would appear slim. 73.6kg on the other hand will likely mean they have a fair fat and/or muscle mass. Both are technically healthy weights. It doesn’t mean someone who weighs 74kg is suddenly a blimp and will develop high blood pressure. However, someone who weighs 90kg at this height will be more prone to health risks in the future.
So take it all with a pinch of salt and demonstrate some lateral thinking when analysing yourself.
Another problem I face working in obesity is motivating patients. An obese 30 year old who has no ill health and does not see any consequences may be unlikely to change. An obese 70 year old with metabolic syndrome can be just as unlikely to change because they view the condition as just part of life.
For every motivated patient there is I can think of many ambivalent patients there are about their health. This is not to stigmatise those patients. It is their body and their choice and I perfectly respect that. It can just be frustrating when a condition like type 2 diabetes can be greatly improved and return so much quality of life to patients by making simple lifestyle changes.
Model of care
In fairness, much is also down to the model of healthcare. We are reactive rather than preventative in most cases. In the year 2016-2017 Public Health Englands net operating budget was £297 million. Compare this to the department of healths planned spending for the previous year of £124.7 billion (Kings Fund) and it is a tiny fraction. Another way of putting it is 2.3% total spend.
It is hard to prevent a fire when you are putting out one, or 50, which would likely be a better example of the NHS currently. Especially on limited funding.
This is one reason little attention is paid to lifestyle remedies in practice. Granted there are some initiatives launched but lifestyle services are always some of the first to go when money needs to be saved.
I worked in weight management upon qualifying as a dietitian and we did some fantastic work (if I do say so myself). Our targets were for patients to lose 10% of their body weight at 1 year because of the associated health benefits. In an 80kg person (12 stone 8lbs) this is losing 8kg or just over 1 stone.
We achieved about a 50% success rate. This was above national average but would appear quite modest to the seasoned dieter. Yet clinically this was significant.
I wonder then what the success rate could have been with more funding or more preventative action. We ended up losing this contract because it was seen as too expensive. Proving your worth in these patients is hard. They would need to sustain the weight lost and then be followed up for many years and compared to non weight loss groups for data.
Often sustaining the weight lost is a problem for patients. They achieve initial success only to relapse sometime later.
As you may have gathered by now, there is only so much we can do as healthcare professionals when it comes to weight management. Most of the change needs to come from the patient. We can support, educate and facilitate but the bottom line ends with the patient. This is why even 10% weight loss is difficult to achieve in only 50% of patients.
The cost of obesity in 2007 in the UK was estimated to be £16 billion with this increasing to £50 billion by 2050. Astonishing figures. Therefore, if you suffer with chronic hypertension, non alcoholic fatty liver, type 2 diabetes, raised cholesterol or high blood fats and you are overweight, the first and likely most effective treatment option is weight loss. If this doesn’t help, at least you have eliminated one cause and your GP can advise on further medical interventions to help.