Obesity - why doctors need to start conversation with patients


Being overweight and obesity are the fifth leading risk for global deaths. At least 2.8 million adults die each year as a result of being overweight or obese. Forty-four per cent of the diabetes burden, 23% of the ischaemic heart disease burden and between 7% and 41% of certain cancer burdens are attributable to being overweight or obese.

The fundamental cause of obesity is an energy imbalance between calories consumed and calories expended. Globally there has been a significant increase in the proportion of people who can be defined as overweight or obese. Max Galka created the graphs below which illustrate these trends.

This increase is seen both countries like the United States and the UK, where food is cheap and abundant, as well as countries like Somalia and Angola, where malnutrition remains an epidemic.

The greatest increases were seen in the smaller Pacific island countries. Samoa, Tonga, and Tuvalu all saw their obesity rates double from what they were in 1975.

Perhaps the country that stands out most of all is China. In 1975, only 0.5% of Chinese adults were obese. Today, China's obesity rate is about 8%, a 16-fold increase in the most populous country in the world.

Globally, the average adult today is three times more likely to be obese compared to the average adult in 1975.

The increase is caused by several factors. These include increased intake of energy-dense foods that are also high in fat; this is compounded by an increase in physical inactivity due to the increasingly sedentary nature of life. Other factors are increasing urbanisation and changing modes of transportation.

Changes in dietary and physical activity patterns are often the result of large-scale environmental and societal issues such as a lack of supportive policies in sectors such as health, agriculture, transport, urban planning, environment, food processing, distribution, marketing and education.

So, how can we tackle this problem? We have dietary and exercise guidance but even when individuals are aware of this, they can find it difficult to adhere to. The government needs to support individuals to follow these recommendations through sustained political commitment. In particular they should make regular physical activity and healthier dietary choices available, affordable and easily accessible to all - especially the poorest individuals.

The food industry needs to support this by reducing the fat, sugar and salt content of processed foods, ensuring that healthy and nutritious choices are affordable to all consumers. They should also be responsible when marketing to children and teenagers.

For your average GP, supporting an overweight patient is fraught with potential issues. Apart from the insoluble environmental confounders (our weather does not encourage folk away from their TV sets) and the usual suspects of poor availability of time and resources, obesity does not follow the classic medical/disease model. It is the patient who ultimately exerts the greatest control over the decision to seek help and, eventually, in the success of any intervention.

As a doctor, you really need to start this conversation but many worry about ruining a working relationship by a few ill-chosen words. The RCGP has some suggestions that should not cause offence, including "How do you feel about your weight?", "We know weight can affect the safety of doing an operation - has anyone talked to you about this?", "When did you last weigh yourself?", "Has your weight changed much over the past few years?" or "Do you keep an eye on your weight?".

You might be surprised that the patient has already been trying to lose some weight, and giving encouragement and following up with "Is it something you would like to discuss further or get some support for?" may be a good way to start. Remember to check that weight management is a priority for the patient right now. For instance, would they be more likely to succeed if any mental health issues were addressed first?

If you feel your skills could do with a little sharpening this year why not check out this RCGP page.

They have an introductory certificate in obesity, malnutrition and health as well as several useful resources for you and your team. If you have motivated staff, you might support them in setting up a 'Fit club'. We have a group of around 15 patients who come weekly and are weighed and then walk over to our local primary school's sports hall where they do a Pilates/tai chi class on alternate weeks. They have all lost weight, lowered their blood pressures and HbA1cs.

It's New Year, a new start. Help people make that commitment to change.



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