It is definitely NOT for any public use whatever, nor intended in any way to be taken as advice for any medical or health condition.
The one nutritional topic that both interests and vexes family physicians more than any other is weight management. Is there anything new to be said, or does anything lie on the therapeutic horizon which might offer improved management for the overweight and obese patient?
The last 12 months have not seen any startling new discoveries which portend instant salvation for your obese patients. But there are some developments that may prove helpful somewhere not too far around the corner.
In the arena of basic obesity research, one of the main thrusts for some time now has been to demonstrate the key role of genetic factors. But this does not mean that current thinking ignores lifestyle factors or is pessimistic about the value of active therapy. The importance of emotional and motivational issues becomes ever more apparent in research studies. Regardless of what genetic hand your patient may have been dealt, there is still plenty of room for lifestyle management betwixt the genes and their final shape and weight.
One of the most important elements of that lifestyle management is now recognised as increased physical activity, even for the seriously obese. From the public health perspective, two population sub-groups which have attracted attention in recent times are the overweight male and children. The overweight male too often has little awareness of the condition the health risk of which they are (literally) carrying, compared with women of corresponding overweight. Regarding children, Australia appears to be suffering something of an paediatric overweight epidemic, and the finger is pointed squarely at decreasing physical activity amongst our children.
On the nutritional side, greater understanding of the energy cost of turning macronutrients into fat has suggested the particular significance of excess fat intake in overweight, and to that extent has lessened the blame popularly attached to carbohydrates as the primary cause. Work on pharmacological solutions is focussing on new drug classes that act more directly on nutritional metabolism, in contrast to the current generation of agents that act via CNS appetite suppression.
Two interesting examples of this are drugs that prevent food components such as lipids from being fully metabolised, and foods constructed with synthetic fats that will not be much absorbed in the first place. The Nirvana that these approaches offer is the ability to eat whatever you wish without penalty. In practice, however, although this Nirvana has been long promised it is has so far failed to deliver.
What does all this mean for the practising family physician? Firstly, although your average patient may well have heard from the popular press that obesity is largely genetic, an active and positive approach to weight management is still entirely appropriate. The easiest way to improve your success rate in weight management is, of course, to identify the milder cases of overweight to work with. As explained in an earlier nutrition column, this means regular routine and opportunistic weighing of your practice population so as to pick up those patients who are in the early stages of becoming overweight (BMI just over or rising towards 25).
Once a person has been identified as having being overweight, the first task is to work out what the problem is in a way which will help you to address it. Simply making the clinical diagnosis of overweight or obesity (and ruling out the obvious medical causes such as hypothyroidism) will not get you there. We know enough about obesity to be pretty sure that it is not a single clinical entity, but a spectrum of problems, many yet to be defined, which all happen to lead to a common anthropomorphic end. So, apart from the usual history and examination to rule out obvious medical causes, your assessment should include at least the following seven key points:
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1. What is the patient's genetic predisposition for body shape and weight? 2. What is the history of their own weight and attempts to lose weight? 3. How is the obesity distributed? Apple vs pear: central vs peripheral obesity. 4. What is the level of physical activity/exercise? What avenues are available to increase it? For example, walking part way to work, taking the stairs instead of the elevator etc. 5. What are they eating? A dietary history of some kind (even if qualitative) is mandatory. 6. What contributing factors are present: emotional, social and psychological? For example, has your patient recently given up smoking? What are their life stresses? 7. What is their motivation like for change, and what potential motivators could be effective? For example: what supports do they have to lose weight? Who does the cooking in their household and are they `on-side'?. |
Only once all this is properly understood is there a reasonable chance of coming up with an effective treatment. Although there are a great many management approaches have been employed over the years, the basics can be well expressed in the concept of the Three E's:
This paradigm captures the basic importance of addressing the patient's self-esteem, particularly (but not exclusively) in women where it is likely to be low.
Some possible techniques for
BUILDING UP SELF-ESTEEM | |
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The `Three E's' concept also stresses the key role of increased physical activity in weight management. This has value not only in increasing energy output and underlying metabolic rate, but also in kicking off lifestyle change. It will also usually produce a quick gain in general well-being, which is an important weapon in the fight to maintain motivation.
Eating habits still have to be addressed. In this arena, the simple act of keeping a diet diary can be very effective not only in diagnosis but as a therapeutic awareness exercise. A diet low in fat but adequate in energy is the current accepted thinking, but the details may well be best worked out in conjunction with a qualified dietitian. There is a role for pharmacological measures and commercial or group approaches to management, such as Weight Watchers, although these cannot be seen as permanent solutions as the thrust of current research makes it clear that these measures work only as long as they are continued.
Taken as a package, the current climate for overweight management remains optimistic, in spite of the undoubted difficulties of dealing with a recurring and chronic problem.
Click here for links to more weight management sites.
Article on routine patient weighing
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