There is no ‘quick-fix’ solution or ‘one-size-fits-all’ approach to tackle the global epidemic of obesity, the EuroPRevent congress in Dublin heard.

Instead, healthcare professionals must tailor weight-loss advice to individual-specific needs, according to Alison Burton Shepherd, nurse tutor at the Florence Nightingale School of Nursing and Midwifery in King’s College London.

Ms Shepherd told the congress that obesity is an ‘incredibly complex’ and ‘very individualised’ disorder, and reviewed the evidence for a number of common weight-loss strategies in her presentation entitled ‘Real life weight loss: what works?’

The strategies Ms Shepherd explored included dietary programmes, public health campaigns, promotion of physical activity, pharmacotherapy, behavioural therapy and bariatric surgery.

Helping patients to achieve weight loss may require a combination of these approaches rather than any single intervention, and what works for one patient may not necessarily work for another, Ms Shepherd said.

Determining the specific reasons why people make the food choices they do is a fundamental prerequisite for weight loss, she added. “Why do people eat the things that they do?” Ms Shepherd asked. 

“Unless we can actually find out what drives people to eat, we’re not going to solve this problem. It’s a very individualised problem, and I believe everybody eats different things for different reasons, and why one individual becomes obese probably isn’t why another individual is obese, and I think that is where the crux lies.

“We need to tailor our advice very individually to individual-specific needs and to empower our clients to take responsibility for their actions.”

Dietary programmes

Dieting is highly ineffective, Ms Shepherd said, with a 95% long-term failure rate and evidence from the British Dietetic Association to indicate that dieting often results in people gaining more weight than before they started.¹

“Unfortunately, in some situations dieting causes feelings of deprivation, and if you’re banned from eating what you really enjoy, this can lead to binge-eating your favourite foods and that can cause people to feel guilty and to say: ‘Ok the diet starts again tomorrow’. It’s an ever-perpetuating cycle which you can’t get out of. 

“From a biological perspective, too few calories and the body becomes quite used to too few calories, so the basic metabolic rate will get lower, you increase your fat storage, and unfortunately in some cases it can actually cause disordered eating, and there is quite a rise in bulimia and anorexia nervosa, particularly among the adolescent population.”

Meal replacement therapies have the advantage of convenience; however they remove responsibility for choice from the individual, Ms Shepherd said. Weight-loss plans based on snacks encourage snacking instead of regular eating and should be avoided.²

Similarly, home delivery diets, while they may work in the short-term, are quite an expensive intervention and also remove personal responsibility. Meals don’t contain fruit, vegetables or dairy foods, which will be an additional expense.

Crucially, the individual must know how to choose and cook healthy food for themselves, rather than relying on someone else to do it.³

Commercial services trump primary care

Commercially provided weight-management services appear to be more effective and cheaper than primary care-based services, especially when delivered by primary care-trained staff, Ms Shepherd said.

A 2011 randomised controlled trial in a primary care trust in Birmingham, UK,⁴ compared a number of weight-loss programmes including Weight Watchers; Slimming World; Rosemary Conley; a group-based, dietetics-led programme; general practice one-to-one counselling; and pharmacy-led one-to-one counselling.

The primary outcome was weight loss at programme end (12 weeks). Secondary outcomes were weight loss at one year, self-reported physical activity, and percentage weight loss at programme end and one year.

All programmes achieved significant weight loss from baseline to programme end (range 1.37 kg [general practice] to 4.43 kg [Weight Watchers]), and all except general practice and pharmacy provision resulted in significant weight loss at one year.

At one year, only the Weight Watchers group had significantly greater weight loss than did the comparator group. 

The authors concluded that commercially provided weight management services are more effective and cheaper than primary care-based services led by specially trained staff, which are ineffective.

Public health campaigns

Public health campaigns are ‘incredibly important’ to educate the general public about the dangers of obesity; however they have not always worked particularly well in the past, Ms Shepherd explained.

The Change4Life programme in the UK is one such programme; however, a possible flaw in the programme⁵ was that the adverts did not mention the word ‘obesity’ but instead used an image-only approach.

The apparent reason for this was that the word ‘obesity’ may encourage deselection.

However, Ms Shepherd said that being overly sensitive is not necessarily in patients’ interest.

“Obesity is a very sensitive subject for some people. And that’s why Change4Life decided to portray it as image-only. I’m sorry, that’s probably a bit too soft-soapy: we have to go in there and be dynamic. People’s lives are being lost.”

One study from Walls et al in 2011⁶ suggested that there is still little evidence that community-based and social marketing campaigns which target obesity provide substantial or long-lasting benefits. 

Drug treatment

Drug treatment may have a place in helping to achieve weight loss, Ms Shepherd said. However, drug treatment is not suitable in all cases and clinicians need to look carefully at their use. Herbal supplements should not be recommended.

“Only after diet and exercise have been started and evaluated, or in patients who have reached a plateau and can’t go any further, should we think about trying drugs.” 

Orlistat is the only recommended anti-obesity drug in Europe, she said, after amphetamines, rimonabant and sibutramine licences as anti-obesity drugs were withdrawn because of their adverse effects.⁷

“I think we really need to start thinking very carefully about its use. Waterfield⁸ suggested very strongly that it should be prescribed as an overall part of an obesity management plan but not on its own. It needs to be used in conjunction with a hypocaloric diet. 

“People, before they’re even referred for a plan with Orlistat, should have a BMI of 30 or more and if it’s less than that they should have at least two comorbidities, including type 2 diabetes, hypertension and hypercholesteraemia. Therapy should only be considered beyond three months if the patient has lost at least 5% of their initial body weight on commencement of drug therapy. And they also need to weigh up the ethics and the benefits.

“I think we should be looking at targeting inhibition of nutrient absorption by drugs, thinking about enhancement of peripheral satiety and adiposity signals, particularly looking at Ghrelin peptide YY amylin, looking at alteration of metabolic rate or substrate use, and thinking about taking action at the central nervous system target, leading to altered energy balance,” Ms Shepherd added.

Practitioners will be familiar with patients enquiring about the use of herbal supplements; however their use is not recommended as some supplements are associated with severe hepatotoxicity⁹ and the efficacy for the majority of supplements for altering weight and body fat remains inconclusive.¹⁰

“We really don’t know what’s in some of these things, and the Ephedra-related compounds are dangerous. They are quite significantly associated with hepatotoxicity, and unfortunately one of the biggest reviews carried out by Laddu et al¹⁰ looking at obesity management suggests that the efficacy of the majority of these supplements for altering weight and body fat is inconclusive. They just don’t work.”

Physical exercise and behaviour change

Encouraging physical activity is a major challenge for healthcare professionals. Many patients believe that they ‘run around all day’ in their normal lives and expect this to be a sufficient level of physical activity.

Bravata et al recommended offering a pedometer to patients and suggested that the use of a pedometer is associated with significant increases in physical activity and significant decreases in body mass index and blood pressure. Whether these changes are durable over the long-term is undetermined.¹¹

Transtheoretical model stages of change (TTM SOC) have long been considered a useful interventional approach in lifestyle modification programmes, but its effectiveness in producing sustainable weight loss in overweight and obese individuals has been found to vary considerably.

Tuah et al in 2011 found that the impact of TTM SOC as a theoretical framework in weight loss management may depend on how it is used as a framework for intervention and in combination with other strategies like diet and physical activities.¹²

Motivational interviewing may enhance weight loss in obesity, and cognitive behavioural therapy can promote weight loss initially and weight regain during follow up.

‘Tele-health’, comprising phone calls and text messages, can support weight loss management.¹³

Online social media like Facebook and Twitter may, however, have a role, Ms Shepherd added, with smartphone apps becoming increasingly popular.

Bariatric surgery

Bariatric surgical treatment should be considered if all of the following conditions are met: the person has a BMI of 40 or more or a BMI of 35 to 40 plus other significant disease that could be improved with weight loss; if non-surgical measures have failed to achieve or maintain clinically beneficial weight loss for at least six months; and if the person has been receiving or will receive intensive management in a specialist obesity service, such as psychological support.¹⁴

Bariatric surgery is shown to offer a more sustaining weight reduction with concomitant improvement to health through resolution of comorbidities, particularly type 2 diabetes, and long-term benefits to the health service, Ms Shepherd said.¹⁵

“In a US study of the cost of gastric bypass surgery versus accumulated savings in drug costs, the savings alone in drug costs were paid for within 32 months of surgery. There was a 32% increase in people being able to go out to work after being obese, and that led to a 66% decrease in numbers claiming state benefit. So there is definitely something in this.

“If you look at prescription cost savings in England, if 10% of people with diabetes actually went out and lost weight, that would save, in the UK alone, £140 million per year, and that’s a lot of money.”

Recommendations

“Prevention is most definitely better than cure,” Ms Shepherd said in her closing remarks. 

“As clinicians we have a primary responsibility to work with overweight and obese people, particularly when they’re demonstrating an upward trend in body mass which you can see when they come and visit you. We need to monitor people’s weight regularly so we can identify a trend. More importantly, we need to get to know that person and find out what is driving them to eat in the first place. Only then can we work with behavioural therapy and motivational interviewing, but again that person is going to need a lot of support. 

“We do need to combine physical activity with energy-restriction if we’re going to promote weight loss. Dietary supplements are not safe; they shouldn’t be used. Evidence-based drug therapy – it may well be useful and there are more drugs in the pipeline. 

“Commercial weight-loss programmes have a place and they can be effective. And unfortunately for the very, very obese individuals when diet, exercise and drug therapy has failed, bariatric surgery, as we have seen from the evidence, may well work.”

References

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3. British Dietetic Association, 2012
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14. Obesity guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. NICE 2006
15. Apau D, Whiteing N. Pre- and post-operative nursing considerations of bariatric surgery. Gastrointestinal Nursing 2011; 9(3): 44-48