management | qof
A total of eight points are available to practices for the correct management and treatment of obesity. Dr PAul lAmbDen explains
Obesity is rapidly becoming the United Kingdom’s biggest health problem with associated deaths estimated at between 10-30,000 a year from obesity alone. Nearly two-thirds (70 per cent) of men and 63 per cent of women are over-weight or obese and it is estimated that, by 2020, one third of adults, one third of girls and one fifth of boys will be obese. Obesity reduces life expectancy, on average, by nine years. The fast food industry bears a heavy responsibility for contributing to obesity and in the UK, over two billion meals from fast food outlets are consumed annually. The cost to the NHS of obesity and its
besity consequences is well in excess of £2bn a year.
The significance of obesity is the range and severity of adverse health
outcomes for which the excessive or abnormal accumulations of fat are responsible. The fundamental cause of obesity and overweight is the imbalance
O between the calories consumed and the calories burned through exercise.
Exacerbating causes include high energy foods and drinks, decreased physical activity due to increasingly sedentary work, greater use of transport and increased urbanisation.
Obesity is defined by the ratio of weight to height using the Body Mass
Index (BMI), the weight in kilogrammes divided by the square of the height in metres. A BMI of less than 20 suggests that a person is underweight, from 20-25 is normal weight, 25-30 is overweight, 30-40 is obese and 40+ is morbid obesity.
Obesity is implicated in the genesis of many diseases and disorders including
diabetes, heart disease, stroke, osteoarthritis, raised blood pressure, gallstones, infertility and depression. None of these is surprising because excess weight places extra demands on the pancreas to produce insulin, adds to the workload of the heart, causes raised levels of cholesterol, causes the weight-bearing joints to have to carry more weight and makes people feel more miserable about their impaired mobility, appearance and poor health. It is alarming that one in three children born in America, where obesity is an even greater problem than in the UK, will develop diabetes.
If the obesity epidemic continues unabated its consequences will outstrip
the resources that the Health Service has to combat it. The seriousness of the problem is recognised in the QOF and a total of eight points are available for the creation and maintenance of a register of obese patients. The principles of controlling weight are simple; to reduce calorie intake and to increase exercise. However, to make changes require alterations in personal habits and are often very difficult to achieve. Encouraging people to walk more, to travel on foot rather than using the car, to climb the stairs rather than using the lift and to take the opportunity to exercise each evening rather than sitting in front of the television often sound better in the concept than in the execution. The NHS does provide exercise programmes at gymnasia under the general title of ‘Fitness for
Life’ and some inroads are being made into the problem. Increasing calories expended is only half the battle. Food consumption must also be reduced.
Smaller portions of more appropriate foods form an essential component. However, reducing the intake of refined carbohydrates may be a major challenge
for many people. It is necessary to burn 7,500 calories more than are consumed in order to lose one kilogramme in weight.
Apart from dietary and exercise help, GPs can prescribe appetite
suppressants such as sibutramine, rimonabant and orlistat but their use should be
monitored to ensure compliance and success and there is NICE guidance
recommending targets to be achieved if the drugs are employed, involving a five
per cent reduction in weight over a three month period.
For patients with morbid obesity, with a BMI in excess
of 40, bariatric surgery can offer a solution. The treatment involves banding or stapling part of the stomach to reduce its capacity. The surgery is not without hazard but the results are often excellent. However it is an expensive procedure, available surgical centres are few and far between in the UK and not all PCTs are prepared to fund the procedure, or require an approval process. It is likely that, over time, greater capac-ity will be made available because the surgery does reduce morbidity with the disorder which, in the long term, is of much greater cost. The obesity epidemic will have to be addressed if huge increases in other diseases are to be avoided over the next decades and the NHS is to survive.
In order to reduce the dose of prednisolone needed the doctor looking after you will often choose to start you, at some point, on an additional drug treatment. In most people the drug used is azathioprine (in some individuals other agents will be chosen). Azathioprine and related drugs are very effective at reducing the doses of prednisolone required to keep autoimmune hepatitis under control
per cent reduction in weight over a three month period.
For patients with morbid obesity, with a BMI in excess
of 40, bariatric surgery can offer a solution. The treatment involves banding or stapling part of the stomach to reduce its capacity. The surgery is not without hazard but the results are often excellent. However it is an expensive procedure, available surgical centres are few and far between in the UK and not all PCTs are prepared to fund the procedure, or require an approval process. It is likely that, over time, greater capac-ity will be made available because the surgery does reduce morbidity with the disorder which, in the long term, is of much greater cost. The obesity epidemic will have to be addressed if huge increases in other diseases are to be avoided over the next decades and the NHS is to survive.