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weight loss. It is never too late to address the obesity issue and benefits are wide-ranging, from ease of personal care issues to reduced utilisation of community healthcare resources, reduced hospitalisation and days off work due to ill-health, and improvements in mental health. In our own practice, a high proportion of obese patients suffer from clinical depression and anxiety that are significantly improved through engagement with BMT and weight loss.
WHAT IS THE PROBLEM? If the issue of obesity in terms of healthcare is ‘simply’ one of making BMT, GLP-1 agonists and bariatric surgery available, then it simply boils down to resources. Unfortunately, it is more complex than this, due in part to the vast numbers of obese ‘non-patients’ whose health is compromised by weight to a significant but non-clinical level, partly due to the vast amounts of money that can be made from the ‘obesity industry’, and partly due to the reluctance of healthcare providers to be seen to impact on personal freedom and individual choice. In terms of advertising, the UK government spends approximately 1% on promoting healthy eating habits as the food industry (including soft drinks companies and chain restaurants) spends on promoting its message. The food industry offerings and the needs of the obese and overweight (plus the inappropriately weight conscious) population in the USA (2007) generated £700 million on meal replacements, £500 million on mail order meal supplements, £15 billion on ‘diet’ soft drinks, and £3 billion on bariatric surgery. Such an industry, as was seen for the tobacco industry, will vigorously defend its position and profitability. In the UK, the average adult is 8.4 kg heavier than was the case in 1980, which requires 196 kcal/day to maintain (the First Law of Thermodynamics pops up everywhere!) and 50 p/day to maintain (or £8.6 bn per year nationwide). An important aspect of ‘the problem’ is the health service itself and human nature. Despite evidence of the effectiveness of BMT being available for more than a decade, it is still not standard practice in many weight management clinical services. The inertia of conventional therapists and the ‘silo thinking’ that often permeates conventional weight management services, mitigates against adopting the degree of change to conventional practice needed to accommodate BMT-based treatments, which are basically patient rather than professionally centred. The absence of robust clinical governance, performance management and rigorous audit of effectiveness of current approaches may deny patients the benefits of modern, validated therapeutic interventions, particularly if they can be delivered by staff from another allied health professional discipline. The ubiquitous nature of the obesity
problem for patients attending clinical services can lead to selective blindness on the
702 THE BIOMEDICAL SCIENTIST
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10 Weight loss in first year (kg) Life expectancy increases with weight loss among obese type 2 diabetic patients.5
part of clinicians, nurses and allied health professionals. For example, how often are obese diabetics told they are “doing fine and are under good control” on the sole basis of an HbA1c result of 60 mmol/mol and a blood pressure of 135/80 mmHg? The fact that they weigh 120 kg, which is at least as big a risk factor for cardiovascular and cancer death as raised HbA1c, blood pressure or cholesterol, is often overlooked and remains unaddressed. In our hospital, a recent survey identified overweight or obesity as a co-existing risk factor in 75% of all patients attending a wide range of medical and surgical clinics, none of which were addressing the issue specifically. Finally, as healthcare professionals, we must all live the health message. Thankfully, the ‘smoking doctor’ has almost disappeared from the NHS. Unfortunately, the same is not true for obesity and a recent survey has shown that 58% of the NHS’s 1.2 million staff members are overweight or obese. In the USA, a stark warning has been issued: “If the current trends in obesity are left unchecked, the current generation of children will be the first in two centuries to have a shorter life expectancy than their parents”. Based on the adoption of current approaches to obesity in the UK, there is no evidence that children in Britain will fare any better. The tsunami of obesity affecting our nation calls for a national crusade.
REFERENCES 1 Mokdad AH, Ford ES, Bowman BA et al. Diabetes trends in the U.S.: 1990–1998. Diabetes Care 2000; 23 (9): 1278–83.
2 Mokdad AH, Serdula MK, Dietz WH, Bowman BA, Marks JS, Koplan JP. The spread of the obesity epidemic in the United States, 1991–1998. JAMA 1999; 282 (16): 1519–22.
3 Mokdad AH, Bowman BA, Ford ES, Vinicor F, Marks JS, Koplan JP. The continuing epidemics of obesity and diabetes in the United States. JAMA 2001; 286 (10): 1195–200.
4 Chan JM, Rimm EB, Colditz GA, Stampfer MJ, Willett WC. Obesity, fat distribution, and weight gain as risk factors for clinical diabetes in men. Diabetes Care 1994; 17 (9): 961–9.
5 Lean ME, Powrie JK, Anderson AS, Garthwaite PH. Obesity, weight loss and prognosis in type 2 diabetes. Diabet Med 1990; 7 (3): 228–33.
SUGGESTED FURTHER READING Crowley V. Overview of human obesity and central mechanisms regulating energy homeostasis. Ann Clin Biochem 2008; 45 (Pt 3): 245–55.
Haslam D, Sattar N, Lean M. ABC of obesity. Obesity – time to wake up. BMJ 2006; 333 (7569): 640–2.
National Institute of Health guidelines (
www.nhlbi.nih.gov/guidelines/obesity/ ob_gdlns.htm).
Ramachandrappa S, Farooqi IS. Genetic approaches to understanding human obesity. J Clin Invest 2011; 121 (6): 2080–6.
Smith SR. A new paradigm for diabetes: weight control. Medscape 2013; July 12.
Dr Michael Ryan is a consultant chemical pathologist and has a particular interest in the practical management of obesity. Dr Cheryl Flanagan, a dietitian and expert in nutrition, specialises in weight management at Causeway Hospital, Coleraine, Northern Ireland. Dr Ryan and Dr Flanagan developed and implemented the Motivate programme, a behavioural modification approach to obesity that has proved successful in achieving clinically meaningful degrees of weight loss in high-risk cohorts of patients.
This article is based on the Vincent Marks Lecture given by Dr Ryan in the plenary session on the last day of the IBMS Biomedical Science Congress.
DECEMBER 2013
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