Challenge on a new Scale
Obesity is growing and so must GPs’ vigilance for cardiovascular disease, says Doug Naysmith
Obesity is one of the biggest problems facing us today – and, unless we act swiftly, tomorrow as well. A House of Commons Health Select Committee’s report in 2005 catalogued the potential health and economic costs that will result from an increase in obesity levels and drew attention to the way that obesity mirrors other health inequalities. The Wanless Report and the Government’s Foresight Report painted a bleak future in which the majority of the country is obese and deaths from heart disease and stroke have soared to catastrophic levels.
Faced with such drastic conclusions we may well feel overwhelmed. The Government, understandably, wants us all to recognise that the solution is not entirely their responsibility but lies in a fundamental long-term shift in the way we design our built environments, and in our attitudes to food and exercise. While considering evidence for the Select Committee report, we visited the USA, Finland and Denmark to see what we could learn that might usefully be applied here. We found that, even in the US, where the problem is greatest, they have had some success in limiting and even reversing the trend – for example, the excellent Public Health programme called “Colorado on the Move”.
Although many of the Health Select Committee’s recommendations were in the field of the prevention of future obesity, we also considered the medical needs of obese individuals now. It may not be realistic to intervene with everyone who is obese but if we are going to avoid a crippling number of people developing cardiovascular and other diseases, we at least need to target interventions at those at a high risk of developing heart disease and stroke.
Two in five adults are overweight, and obesity has more than trebled in the last two decades. This is a major contributor to heart disease, which affects more than one in five, and to Type 2 diabetes, which, if unchecked, is set to rise 50% by 2010 from its 2004 level of two million people in the UK. Make no mistake: these individuals and the NHS will suffer if we ignore our current failure to intervene effectively.
We were concerned that many clinicians viewed obesity as a lifestyle issue rather than a serious health problem requiring active management and we were convinced that managing weight problems sensitively requires specialist skills. We identified a disappointing low priority given to obesity in the GPs' contract and urged NICE to reverse this in its 2006 guidelines.
Overweight and obesity are considered to be the main modifiable risks associated with coronary heart disease and cardio-vascular disease yet Target1000.org - a joint campaign by H·E·A·R·T UK, National Obesity Forum, Primary Care Cardiovascular Society and Primary Care Diabetes Society demonstrates that the systems are not in place in the NHS to help these people. We lack the ability at a primary care level to systematically identify those obese people at a high risk of developing obesity related diseases. In addition, once identified – in spite of the NICE recommendations – the weight management programmes, and expertise in primary care, are not universally available across the country.
The evidence is that these programmes can be effective and cost effective and we know that if people lose weight, their blood pressure is reduced, their lipid profile improves and their blood glucose goes down.
In current clinical practice assessment of a person’s risk of developing heart disease and stroke is dependent on whether they consult their GP and whether a risk factor such as high total cholesterol or high total blood pressure is identified opportunistically. A more systematic approach to risk assessment – a National Risk Assessment Programme – would ensure that more of those patients at a high risk of cardiovascular disease are identified. These patients can then be offered lifestyle advice, support and targeted interventions that would cut their risk dramatically.
The evidence that GPs can effectively manage obesity is strong. The ‘Counterweight’ programme has quite clearly demonstrated that. About 40 per cent of patients entering the programme achieved a greater than 5 per cent weight loss and maintained it for two years. That converts into a loss of at least 15 per cent in visceral fat, dramatically reducing the development of type 2 diabetes and the risk of cardiovascular disease.
The health economics of the situation are also quite clear. Using data from Counterweight, it has been clearly demonstrated that it is genuinely much cheaper to provide weight management in general practice than to do nothing at all.
Our challenge is to ensure that as well as focusing on the societal change needed to prevent obesity we also focus on improving the management of obesity once it appears, to prevent these individuals from going on to develop cardiovascular diseases.
Dr Doug Naysmith MP, Chair of the All Party Parliamentary Obesity Group and Member of the Health Select Committee
