Comment

Turning obesity around

NHE editorial board member Dr David Haslam, chair of the National Obesity Forum and an ambassador for National Obesity Awareness Week, which takes place between 13 and 19 January 2014, discusses the problems facing primary care and what can be done about it.

These are the facts. Only one in three men in England had what would be considered a normal body mass index (BMI) in 2011, according to figures published earlier this year by the Health and Social Care Information Centre (HSCIC).

The findings for women were no better, while the HSCIC also concluded that there had been a startling increase in the percentage of men (13% to 24%) and women (16% to 26%) considered obese in 2011 compared with 1993. Even one in three children was found to be obese.

BMI has now taken a back seat to body morphology in the eyes of obesity experts, but these figures shock and leave absolutely no doubt whatsoever as to the scale of the obesity problem facing the UK. And this is just the tip of the iceberg. Because addressing all of the problems associated with obesity is placing unsustainable demands on the resources of the NHS, which are already under intolerable pressure. The idea of a massive funding gap in the health service by 2020 has long been mooted, and it is difficult to see how these doomsday predictions will be avoided if the cost of obesity to the health service rises further, as it surely will.

Counting the cost

The Office of Health Economics’ report ‘Shedding the Pounds’ predicted that we could have a population in which half of its adults are obese by 2050; while the Foresight Report has suggested that the cost of obesity could increase to an annual bill of £49.5bn by 2050. This could, quite conceivably, be conservative. So something is clearly going wrong with how we’re tackling this problem.

The issue is two-fold. From the patients’ side, there is still an expectation that there is a quick fix that in most cases simply doesn’t exist. A trip to the GP is supposed to yield the appropriate medication and some guidance that they may or may not heed. But all too often there is a gap in expectations, with patients thinking either that their solution can be found in taking the medication prescribed to them, or requires fundamental lifestyle change, overhauling their diet or taking on Olympian levels of exercise. Unsurprisingly, many are disinclined to take action on their own.

An anecdote demonstrates many patients’ limited willingness to act in their own best interests. A patient called, explaining that he was staying in a flat round the corner from my surgery for a few days, but had forgotten his blood pressure tablets and wasn’t able to leave. I offered to drop some of the tablets off with him, only to be confronted by the sight of him chain-smoking, surrounded by empty lager cans and fast food cartons. The message couldn’t have been clearer: I want your help, but I’m not prepared to help myself.

So if the country’s obesity epidemic is to be turned around, greater levels of patient engagement are required. But that is not the only challenge we have to overcome. The sad fact is that while enormous demands are placed on GPs and primary healthcare professionals, there is very little in the way of demands or incentives to take action on the subject of overweight and obese patients. If anything, the opposite is true.

Misaligned incentives

GP practices are assessed according to the Quality Outcomes Framework (QOF), which measures their performance against numerous indicators. Practices receive financial incentives to meet these indicators.

But for obesity it is sorely lacking. GPs are only required to register the number of obese patients they have on their books. There is no incentive for them to help patients get off this register. In fact, they are effectively financially penalised if they do so.

The situation is completely counter-intuitive, and surely it would make far greater sense to give GPs every encouragement to get their patients off a register than putting them on and leaving them there. But even this only scratches the surface.

Across primary care there is a significant knowledge gap when it comes to obesity, weight management issues, and the support services available. With the volume of demands on GPs time and the range of patient needs they have to address, this is hardly surprising, but the fact remains that any response to the obesity epidemic is limited if the professionals on the frontline do not have the necessary information and knowledge at their fingertips.

That’s the problem facing primary care. The question is: what can be done about it?

QOF – unfit for purpose

First and foremost, the Department of Health can and should amend the Quality Outcomes Framework. It is simply unfit for purpose in its current form, effectively ignoring one of the greatest public health crises of our time.

Changing it would cost nothing and cause minimal disruption, but would have a major impact if it not only required but empowered GPs to do more than register their number of obese patients.

The result would be that GPs would be encouraged to discuss weight management issues with their patients and how it relates to their everyday quality of life. This would raise awareness amongst patients, many of whom will not realise that their joint pain or shortness of breath is caused by weight, and that their wider weight management problems must be addressed.

The second thing that has to happen is that there needs to be more information for GPs – who need to be encouraging greater knowledge and specialism in weight management issues within primary care. This requires the promotion of the accreditation schemes that exist within the UK (the National Obesity Forum’s is one), which provide cost-effective models to increase professional awareness of obesity.

This will help ensure that GPs are working proactively to identify obesity and its associated problems, which includes measuring patients’ waists – a fairly obvious step, but one that the International Chair for Cardiometabolic Risk has proved can identify ectopic fat that causes significant health issues.

Bariatric surgery

Thought is needed about how the NHS is deploying its bariatric resources, including surgery where necessary. Bariatric surgery – that is gastric bypass, sleeve gastrectomy, and occasionally gastric band – are generally considered lifesaving interventions, not a proactive measure. But it could be – albeit in those situations where dieting and physical activity alone are unlikely to create the weight loss necessary to move a patient out of danger.

There is ample research to show that, used properly, bariatric interventions can lead to rapid weight loss and address conditions such as diabetes, sleep apnoea, cardiovascular disease and cancer. It is a precious resource, but one that is often misused. The result is that it is not saving the NHS as much money as it could.

That is what can be done from the healthcare professionals’ side. Clearly there must also be action on the part of patients, who cannot rely solely on prescriptions or even surgical interventions to help them. Tackling obesity will only be possible if patients are willing to commit to lifestyle changes that will support whatever prescriptions they are given or weight management services they are referred to.

This requires a change in mindset that primary care must support. There is a tendency to assume that ‘taking action’ means that action must be drastic. A patient has to go on a strict diet or has to start exercising regularly and vigorously.

In some cases that is appropriate, but in many more it is not.

And perhaps the biggest thing the health service can do is reinforce the messages of some its initiatives, such as Change4Life, that tackling obesity doesn’t have to involve soul-searching sacrifice. Rather, to be successful, it requires manageable change.

Sticking to small, sensible changes

This is the message behind the inaugural National Obesity Awareness Week, which is being organised in partnership with the National Obesity Forum between 13 and 19 January. Our aim for the week is to turn obesity around – an admittedly monumental task, but one that should and must be attempted, and which can make inroads into the public health calamity that is obesity if steps are taken to encourage more proactive engagement with weight management within primary care, and above all if the public can be shown that good health doesn’t require hours of exercise or a monastic existence.

Rather it is about the small and sensible changes that we can not only make, but are able to stick to.

NOF are asking the public to join us in a National New Year’s Resolution to tackle obesity by making their own pledges of the small changes they can make in their own lives.

We encourage everyone within the NHS this January to both think what they can do personally to help themselves and what they can do professionally to help patients. Perhaps if we all work together, we really can turn obesity around.

(Image: AP Photo and Gregorio Brogia)