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Joining Forces to Tackle Obesity, 21-22 January 2002

Transcript : Improving Management and Treatment

Speakers

Mrs Drysdale, Mr and Mrs Nixon and Mrs Pack
Parents of children from Carnegie International Weight Loss Camp

Professor Peter Kopelman
Professor of Clinical Medicine, St Bartholomew’s & the Royal London School of Medicine & Dentistry, London

Dr Ian Campbell
GP, Chairman of the National Obesity Forum

DR WILLIAM DIETZ: We’re quite privileged to have three sets of parents and one teenager who have been to the Carnegie International Weight Loss Camp, which is run by Paul Gately, who have generously agreed to share their experiences with the National Health Service as a kind of first-hand testimonial to the difficulties that one has with an overweight child or teenager. From your left to right we have Mrs Drysdale and her daughter Emma, Mr and Mrs Nixon, and Mrs Pack. We’re going to allot each of them a few minutes to share with you their experiences of being a parent of an overweight child and the difficulties they’ve had in getting treatment. Mrs Drysdale?

MRS DRYSDALE: Hello. First of all, if I could just say, my husband and I used to both be smokers up until four years ago when we both gave up smoking. My husband smoked 30 a day. I smoked 20 a day. He’d smoked for 20 years. I’d smoked for 15 years. That was really quite easy giving up smoking, and neither of us has touched a cigarette since, over four years ago. That was quite easy compared to tackling our family obesity problems.

When Emma was nine or ten, I realised we had a problem that we couldn’t deal with and I went to our local GP. I was told at that initial session that it was just puppy fat and I was being a bit paranoid as a mother and really she’d grow out of the phase. About a year later I took Emma back and said, "I really do need help. I can’t cope. It’s a problem that’s causing a lot of stress at home and we can’t deal with it". And the GP in Newcastle where we lived at the time, set up an appointment for us to see a dietician.

We had a 20 minute session with a dietician the following month, at the end of which they congratulated me on educating Emma in a good healthy food diet, and said that she really did know the difference and it’s quite sound at her age to know the difference between right food and wrong food to eat. And that was about as much as she could do, other than give us some diet books, good healthy foods, eating books to take away.

A year later we moved up to Blythe in Northumberland and when we were just registering with our local GP up there, we brought the issue up again as something that we felt that we couldn’t control as parents and we needed help with. The local GP up there said that he’d arrange for us to see the local dietician. I’d explained we’d seen one before and he said we still needed to go and start off by seeing a dietician. I think we were with that one for about 10 or 15 minutes before they turned around and said really, she couldn’t help us and we needed to go back to the GP for further referral. So we went back to the GP again and at that point the GP said that really we knew the difference between right and wrong foods, we were fairly intelligent people and that we really needed to just get on and sort things out. I wasn’t happy with that and I made a subsequent appointment to go back again, being a bit of pain, and using up all my five-minute sessions and I insisted on having more help. At that point they said, "Well, the only help we can give you is to send you to the General Hospital Newcastle - the children’s psychiatric unit". So I said, "Right, great, whatever, anything you can give me please".

So we went to the General Hospital Newcastle and saw the psychiatrist there for about four or five sessions, I think, at the end of which, certainly during which, it became self -- "Emma doesn’t shoplift, she’s not in trouble with the police, she goes to school every day, she’s not addicted to drugs or drink, what’s your problem? She’s quite a healthy kid." During all of this Emma was increasing her weight and so were we, my husband and I, especially from giving up smoking. It got to quite a critical point and we went back to the GP about 18 months ago and said, "We’ve tried the dietician, we’ve tried the psychiatrist, we’ve tried helping ourselves. We gave up smoking - that was easy. We’re having a significant problem with this and the situation’s getting worse because now Emma is having to stay in and study for her GCSEs, the more we were able to restrict what were able to do as a family about her exercise-wise". At that point the GP said she was very sorry, she felt there was nothing more she could do for us. She herself said that if we were addicted to drugs in Blythe that about practically £7,000 per person per year. If we were addicted to drink there’s about £1,000 or cigarette smoking is about £1,000, by the time you add up all the chemicals and the counselling sessions that were available at the time, and unfortunately because we’re addicted to food and bad habits -- and just constituting that there was nothing that she could do for us and was quite open and honest.

So we left the GP and the NHS feeling that this is a problem we had to deal with ourselves and really never got to the root of the problem until Emma herself came to us one day and she’d seen something on the television about "Fat Camp", as it was advertised at the time, and said that she really wanted to try it. Because Emma herself was motivated to try it we felt okay and we went back to the GP, well, we spoke to Paul Gately first, who runs Carnegie International Camp. He said that we might be able to get some financial help from the local NHS and it was worth trying and going and seeing if we could get any support or help.

WILLIAM DIETZ: Mrs Drysdale, please, could you just sum up?

MRS DRYSDALE: I’ll pass over to Emma and hopefully she’ll give you the benefits of what we got, but the short end of this is since going to the camp, as a family, and Emma will tell you herself what she’s gained from it, but my husband’s lost nearly a stone so far, I’ve lost two stone and we’ve made some massive significant changes in our lifestyle since then.

WILLIAM DIETZ: Thank you. Emma?

EMMA DRYSDALE: My name’s Emma Drysdale and 8 months ago I weighed 19 stone and 4 pounds and I now weigh 16 stone and 6 pounds. That’s a loss of just under 3 stone. I just feel that before I went away to camp the situation that I found myself in was becoming more and more desperate. I was becoming depressed, my parents were getting more and more stressed about trying to help me and it seemed like nobody else cared. Whenever I went to the NHS we were constantly referred and it was: yet again they couldn’t help us. It’s not like we were embarrassed to seek help. I went out looking there for help. It’s just there was none to receive in the first place. I am 16 years old and I’ll tell you now, teenagers have far more things to worry about than being able to fit into standard size clothing. I’m very thankful that we had the financial resources and the intelligence to not give up and to help ourselves. Carnegie Camp was our last resort and I’m just so happy that I can now understand how to live healthily and normally and this has really benefited me. But yet, how many others are in the same situation as I used to be, if not worse, and how many times do they have to be referred and how much more do they have to suffer? I think people need to realise that we do need help and it’s not just a case of: sorry we can’t help you, sorry we need to refer you to someone else, there’s nothing more we can do, because then people give up.

WILLIAM DIETZ: Thank you, Emma. Mrs Nixon?

MRS NIXON: Our son attended Carnegie after many years - up until the age of 12 - being told by the GP, "Oh no, you don’t diet a child under 14. No, it will sort itself out. He will grow out of it". We hassled and hassled. We eventually saw the dietician attached to the local GP. "He’s okay, he’s a solid lad, he’ll be okay". And then when it was actually recognised as being a problem, it was our problem. Same as Mrs Drysdale’s, continually going round in a circle, back to the GP. "Oh, yes, yes, we will look into it, we’ll sort this out, we’ll sort it out" and nothing happened. A new GP joined the unit. We were fortunate enough to see him. He referred us to the hospital where we saw a dietician and a paediatrician there who said, "Well, it’s a long shot, but there’s a Fat Camp. It’s based in Leeds. It’s local to where you are. You can give it a go. You may get help from the health authority, you may not". Unfortunately we didn’t get the help from the health authority, but we had funds to be able to go there. Our son went and it’s proved, as Emma said, it works. We’re not the only parents that have this problem. There’s many parents out there that do have it, and yet we’re constantly told, "Oh no, it will sort itself out" and it doesn’t.

It would just be nice if the health authority could help us to help ourselves as opposed to just telling us, "Yes, well, eat less, exercise a bit more". We’re not given the proper advice. We’re told at a high level what to do, but it’s the detail that we need which we got from Carnegie Camp.

MR NIXON: Yes. I’d just like to add, even simple stuff like information on what’s a healthy diet was really difficult to come by. There’s quite a lot of conflicting advice. We went to see the GP and he said, "Oh well, you’ve got to eat less". He actually doesn’t eat anything more than us. He eats a fairly healthy diet that’s low in fat. It’s partly low calorie diet. We were always made to feel that his weight problem was somehow our fault. We tried to get him into exercise programmes, things like that. We had a lot of difficulty getting him into a group to play sports. It’s quite difficult for kids that are overweight to actually get into football teams and things like that.

So generally we always felt that things were really, really against us and that we just had no help from anyone. When we actually went to try and get help to fund the visit to the Carnegie Camp, we tried things like the health insurance. We were told that "No, it’s not a life- threatening disease" which I actually think is wrong. A few years down the line it can actually result in quite serious health problems. There was no help from the NHS and again, it must be impacting the NHS that we’ve got problems with obesity, resulting in heart disease and all kinds of problems.

WILLIAM DIETZ: Thank you. Mrs Pack?

MRS PACK: My son Oliver is 15 years old and he’s the eldest of my 4 children but the only one with a weight problem. His problem started five years ago when my husband died. He gained weight very rapidly at that time. I was concerned after about six months and I took him to see my GP. He decided the best course of action was to send Oliver to a bereavement counsellor, and he went to the bereavement counsellor for a year and actually that was very good, it helped him come to terms with the death of his father, but unfortunately the weight gain continued very rapidly.

At 13 years old I took him back to see my GP because I really was getting concerned. He was starting to be teased at school. He was becoming very depressive and introverted. He wasn’t taking part in sports and he wasn’t wanting to be part of the rest of the family. My GP, who is a very sympathetic man, actually scratched his head and said, "Well, Oliver, what shall we do with you?" He really didn’t know what to do at this point, but he decided the best thing was a referral to a paediatrician for physiological tests. Then we went to hospital after a few months’ wait.

The paediatrician actually didn’t carry out any physiological tests at all. He just took one look at Oliver and said, "Well, young man, you’ve got to start eating less". The most damning thing that happened at that interview for me was that I’d been desperately trying to get Oliver to be more active and less sedentary, and as a family we’d been swimming, cycling, walking. He just didn’t want to take part in all of those activities. It seemed to be all a waste of time. The paediatrician said to Oliver, "I wouldn’t worry too much about exercise, Oliver. It wouldn’t matter if you stood on a treadmill for ten hours a day. You just need to stop eating doughnuts". Now that was a dreadful thing as far as I was concerned. It just wiped every effort that I had made.

Anyway, the only positive thing to come out of that interview was a visit to the dietician. We waited another couple of months to see the dietician. Unfortunately very similar to the other stories: the dietician just said to me, "Yes, you’re doing all the right things. It’s clear because you’ve got three normal children. I can’t really help you. Just don’t eat so much Oliver". I asked her, if he followed a set diet, perhaps if she prescribed a set diet and he used it as medication, he would stick to it, and could I have some follow up weigh-ins. And she said "Oh no, no, I’m much too busy. I’m under-resourced, this department is under-resourced and I’ve got children out there with allergy problems, I’ve got children out there who are diabetic. Mrs Pack, your son’s overweight. That’s your problem". Well, that was the inference anyway.

So I went back to my GP. At my suggestion I asked him if he would do weekly weigh-in sessions for Oliver if he followed a strict regime diet and he said, yes, that was a splendid idea. But it was impossible to put into practice.

At that point I also saw a television programme about the Carnegie International Camp and I discussed it with Oliver and I took the matter into my own hands and I decided to put him on a six-week course last summer. It’s the best and most positive step forward that we’ve taken and also of course there was no other real option. Oliver did benefit hugely from the camp. Not only did he lose weight but more importantly, it’s the first time that he’s been able to swim and play sports unselfconsciously, without teasing. By now Oliver is seriously obese. At 14 or 15 years old he weighed in excess of 17 or 18 stone, but now he has a much better self-acceptance and he’s got much better self-esteem. He’s continued 100% with the fitness programme since returning home, and although his weight loss hasn’t been as consistent, he’s just holding his head up. The difference is phenomenal.

So really to sum up, I’d only like to say that there just isn’t any joined-up or integrated therapy. GPs just don’t know what to do. With the best will in the world they’ll sit there, sympathetic, but on the whole they’re scratching their heads. There’s no treatment available, and worst of all, you’re made to feel unimportant and time-wasters by many health professionals. I don’t know what the answer is, but I feel it’s vital that obese sufferers, and especially when actively seeking help, are not made to feel hopeless or difficult to deal with. The whole business is frustrating and fraught and miserable and if it’s this hard for people trying to seek help, imagine what it’s like for those who don’t even know they’ve got a problem. Thank you.

DR WILLIAM DIETZ: Thank you very much. Thank you all very much for sharing your experiences with us. We’re very grateful for the time you spent. Thanks. Now I think we’d like to go on to the next part of the programme. If the panel could step down, and I’d like to introduce Peter Kopelman. Peter is Professor of Clinical Medicine at St Bartholomew’s in the Royal London School of Medicine and Dentistry, and will be speaking just today, I think, on the treatments.

PROF PETER KOPELMAN: Thanks Bill, and thank you to the families. I must say that’s quite a difficult task to follow. What I’m going to do is talk about trying to improve the management and treatment for people with weight problems.

[slide 1] I apologise, you’ve seen this prevalence chart before. But I think it is so stark, it is so worrying, that we need to return to it. But I want to also highlight on this some changes within the health service. If we take 1985 we had the Griffiths Report. In 1989/1990 we had the Clark Reforms that led to the purchaser provider split. In 1992 we had The Health of the Nation, which for the first time set a target to reduce the prevalence of obesity in England and Wales back to the 1980 prevalence rate, 6% of men, 8% of women, by the year 2005. 1996, The Healthier Nation, those targets were dropped. We now have the NHS plan and I really commend the National Audit Office for focusing and highlighting the problems that we face with obesity. What we now have to do is to meet this challenge. It’s the challenge of trying to prevent the problem. It is also to face up to the reality that we have a major problem currently within our mass. [slide 2] If you take a whole centre, you could actually now suggest that if there’s a population of about 10,000 adult patients, anything up to 4,000 of those adult patients may be overweight and indeed 3,500 may be obese. You will notice also the increasing numbers of children that face this problem. I’m going to focus on the management of adult overweight and obesity.

But one of the problems we face is that, of course, there are other priorities. Primary care is now beginning to really struggle under all these obligations. I would suggest it is quite disappointing at this conference that there are so few doctors here, but just as importantly there are - as far as I can see on the list - no chief executives of trusts, nor medical directors or representatives of strategic health authorities and we do really need to address this from a health concern, across all the boundaries of the National Health Service.

[slide 3] It’s also important to relate - and this is a scheme, it’s just a cartoon - but if you look at the bottom here, this is increasing body mass index. But remember, if we look at risk of ill health, risk indeed of early death that relates not only to being overweight but also in being underweight. Across the world and even in this country, we still see people who are malnourished, and what we need to do is improve the education of health providers to understand and recognise such individuals. We need to actually increase our knowledge because this, as I say, is schematic, but the evidence suggests that there are ethnic groups in whom underweight and overweight actually causes greater problems at a lower level.

[slide 4] I’m going to medicalise obesity and overweight for a few moments and I don’t apologise for this because this is the way that we’re going to engage professionals within the health service. This is a slide that looks at the relationship between, on this axis here, increasing body mass index and the risk or chances of developing type 2 diabetes, formerly known as maturity onset or adult onset diabetes, and now, as you’ve heard, a condition that we see in young. If you look along this axis it shows very clearly that increasing body mass index is associated with increasing risk of type 2 diabetes. But it also indicates that it’s not only the overall fatness, it’s where you deposit your fat. Our knowledge now about abdominal or upper body obesity: apple-shaped obesity, confirms that increasing waist circumference or fat being positioned around the midriff, is just as much a risk for the development of not only diabetes, heart disease, hypertension and many other conditions.

[slide 5] When we come to the actual intervention, one of the problems we face is that people still do not recognise obesity as a risk factor for diabetes or cardiovascular risk. If we look at this slide and we look again at increasing body mass index, and we look at the association with risk factors for heart disease, at the top here we have an increase in total cholesterol. Here we have an increase in triglyceride and other components of blood fat level. The red line, which is shown here, is the increase in systolic blood pressure. Now as a doctor, I would have no concerns about treating the total cholesterol, nor the blood pressure. I personally wouldn’t have any reluctance in treating the obesity, but there are many colleagues who would not recognise that as a problem. What we need to do is recognise this as a problem and intervene earlier.

[slide 6] So why the problem? Well, we’ve heard about this on many occasions. It’s the environment. The epidemic of obesity is not reflecting a shift in our genes. Indeed those genes that may well be partly causative or predisposed are the survival genes for the past. It’s simply the environment: it’s grazing, it’s physical inactivity and it is leisure inactivity. (I promised Phil I wouldn’t mention pretzels this morning.)

[slide 7] So if we look at it in this way, how are we going to improve treatments and management for obesity? Well, I think first we have to recognise it is a legitimate and chronic disease, that there are serious health consequences and it is a major risk factor for common causes of death. We’ve heard about the National Service frameworks, we’ve heard about coronary heart disease, we’ve heard about cancer. There is a close relationship between increasing body weight and risk of developing those problems. Secondly and importantly, there are multiple causes. We have emphasised the relationship with the environment. Yes, there is a genetic predisposition, but no one is pre-destined to become obese. But what is very important is that there is no purpose in blaming the individual. It’s inappropriate and certainly does not produce a positive outcome. And finally, there are many treatment options, and the evidence base now is showing that they are effective, and we need to get that message across to the individual who is suffering, but also, importantly, to the health care professional. I will review some of these treatment options through my talk.

[slide 8] But it is important also to set an achievable weight loss goal to that individual who is suffering from overweight or obesity. Many of my patients - unfortunately in fact many of us in the audience with increasing age - will put on weight. In some circumstances, particularly perhaps the older patient, it may be appropriate for them to actually simply maintain, rather than lose weight.

The expectation of many, and certainly the societal pressure, and I would suggest inflamed by certain elements of the media, is the ideal body weight. What is an ideal body weight? I have no idea. What we’ve got to do is to achieve a desirable weight loss that actually leads to weight loss that is, as I’ve said, achievable, to give that individual confidence to lose more. The evidence base again is that 5 - 10% reduction from the initial weight is certainly of benefit to that individual’s health. [slide 9] That summarises those benefits on this slide and indeed, in clinical practice, it is quite dramatic. If you take an individual who is 100kg in weight and you get them to lose 10kg in weight, the reduction in blood pressure is actually 10mm in mercury, both systolic and diastolic. That really does happen in most circumstances, which is very, very dramatic and impressive by comparison to any anti-hypertensive medication or tablet. So there are major benefits from relatively modest degrees of weight loss.

What then are the primary interventions? [slide 10] How are we going to help people to lose weight? I’m talking from a clinical point of view. Well, it’s interesting, that slide, from the evidence base before, indicating the benefits of a low calorie diet. [slide 11] This slide is to illustrate that yes, a balance deficit, that’s a calorie deficit diet, leads to weight loss and leads to very significant weight loss. By contrast, this is a very low calorie diet that you can actually put here: "crash diet". So many magazines give you the "crash diet" to get into that bikini for summer. What happens of course is rapid weight loss followed by weight regain. So it’s the long-term calorie restriction. But again, as the evidence base has shown, [slide 12] this should be combined with physical activity and ideally with some form of behaviour therapy. This rather complex slide indicates that if you can afford it - and we have not talked about resources and additional resources to achieve weight loss - then if you can combine behaviour therapy, physical activity and various other elements, you will see long- term benefit. So there are simple measures [slide 13] that are actually very beneficial and this, as you’ve heard, has now been very much delegated on to a local level, into the community and primary care.

Yes, we should be doing opportunistic screening, not only in primary care but also in the hospital sector. I’ll come back to that in a moment. It is important to involve the whole family. We do not use the opportunity in the workplace to help people understand about their weight problems and help people to reduce their weight. We have heard a little bit about exercise. We will hear more this afternoon, and some of the successes and failures of exercise prescription, and finally, dare I say it, the links with the private sector, commercial slimming organisations are very successful for certain individuals. Again, I am surprised that they are not represented at this conference. But it’s trying to develop something on a local basis, which doesn’t necessarily have to be in the private sector, providing there is local resource to support an equivalent.

[slide 14] What about secondary intervention in the sense that if the primary intervention in certain individuals doesn’t achieve this desirable weight loss, then it may be appropriate to consider drug therapy? One of the problems about drug therapy is partly the public misconception, and that’s very much again inflamed by the media: there is a "slimming drug" to cure obesity. It’s always headline news, when in reality there will never be the perfect drug to cure obesity. The second is that the health profession are understandably sceptical about the advantages and benefits of drug therapy. In all reality we have not had a good track record. If we accept that there is a role for drug therapy, then it is important to have criteria about the suitability for prescription, where diet and exercise have not achieved acceptable weight loss in someone either at risk from their obesity or with established complications. I’ve taken the remainder of this slide from the Standard Medical Advisory Committee’s recommendations for the use of an anti-cholesterol agent and all I’ve done is substituted weight loss for lipid lowering. So weight-lowering treatment should be targeted at those at high risk from obesity and not obesity alone. The message there is if you’re at medical risk then it’s appropriate to prescribe. If it’s simply a cosmetic problem then one should perhaps have more doubts.

The first priority is patients who have obesity with established metabolic complications. I’ve already covered those instances at the first part of my talk. The second priority, are those with physical restriction. We see many young people now who are physically disabled by their obesity - they are breathless on slight exertion, they are developing arthritis. Finally and importantly, if you take a good history from someone with a weight problem, quite often you will find that that it actually runs in the family and that there are serious medical complications associated with that in the family. [slide 15]

If we then accept that drug therapy might be appropriate, what one has to understand is, not surprisingly, not everyone responds. This is a slide that illustrates that if you prescribe a drug, then, in fact, surprisingly, up to about 60% of individuals actually get benefit. There are 40% who do not, and of those 60% then the vast majority continue to have benefit whilst that drug is prescribed. But of course the licensing limits the use of those drugs up to one year or two years for Allistat in certain circumstances.

[slide 16] I’ll just briefly review the two drugs that are now available in this country for use in obesity, and both have Nice guidelines, which were published last year. Let’s start first with Cybutamine. Cybutamine works centrally; it’s a receptor uptake inhibitor, so it harnesses the central effects of serotonin and more adrenalin, which suppress the appetite. So it’s a centrally acting appetite suppressant. In trials it is very effective in reducing body weight. [slide 17] This is a study that was published by Phillip James and colleagues at the end of 2000, which shows in an open label part of the study - that everybody knew that they were taking the drug - there was a very significant weight loss. Those who continued on the tablet maintained that weight effectively for the two years of the study, whilst those who were randomised onto an identical but inactive drug, a placebo, regained quite a bit of the weight they had lost. So it works in certain instances for certain patients.

[slide 18] Similarly there’s another tablet called Allistat, which has Nice guidance, which works very differently. This works within the bowel, and what it does is it partly inhibits the digestive enzyme that enables fat to be absorbed. So if a patient overindulges with fat, fat in their diet, boy, they know it. They get oily discharge, or very offensive diarrhoea, and in a sense it works like Anti does for alcohol. It actually makes someone stick to a low-fat diet and is again successful in clinical practice.

[slide 19] This next slide is very similar to that Cybutamine slide in the sense this is the weight loss over time. Those are the patients on the Allistat. At one year they were randomised either to continue on the Allistat or to go onto a placebo and you see those then seemed to regain the weight. Interestingly, those who started on the placebo, when they were randomised either to continue onto a placebo or go onto Allistat, despite being on what was supposedly a weight maintaining diet, they actually lost weight.

So these drugs do work, both in the trial situation and within the clinical setting, and I’ll show you some evidence for that in a moment. [slide 20] In addition to the benefits of just simply weight loss, we mustn’t discount those other advantages. This is with Allistat, showing that there is a fall in LDL cholesterol. That’s the cholesterol that you want to have the least of. It’s the most pathogenic. With Allistat there is a very significant reduction, partly explained by weight loss, but also explained by the fact that they have to stick to a low-fat diet. So there are advantages from drug treatment. We are moving forward. There are a large number of drugs in development. [slide 21] Having said that, it is important that we use them appropriately.

I’m moving now just on to management within hospital, because nutrition in general - and that’s both under- and over-nutrition - should be very much part of clinical government, and it doesn’t seem to -- well, it is there, you heard about hospital nutrition, but in the sense of continuing professional development and education, disappointingly it doesn’t seem to have a high profile. And importantly within the hospital setting, we need to have hospital -- multi- professional teams, nutrition advisory teams that, at the present time, seem to just simply look at underweight individuals; we need now to address the overweight individual as well. I always find it frustrating on the post take - that’s post emergency-take ward round - with my cardiology colleague on the coronary care. So many of those patients are overweight. We don’t take that opportunity then to intervene with nutritional advice. And then many of those have high cholesterols, and we seem to prescribe rather than using other primary interventions in the first instance.

[slide 22] What about then the tertiary intervention, the surgical treatment? It seems in a sense rather sad that in the 21^st century the most effective treatment for treating those who are very obese is splitting up their stomach. This illustrates the types of methods we can do that. This is the vertical band, a gastroplasty with staples down here, and a band around the stomach. This is simply putting an adjustable band around the top of the stomach. Or you can do a more dramatic treatment, actually to section off the top of the stomach and then put a loop up of small bowel here, so you bypass the remainder of the stomach. This is a very effective way of inducing weight loss. [slide 23] This is from the first two years (it’s now been going for eight years) of the Swedish Obese Subjects Study. What it shows is very significant weight loss with each of these types of gastric surgery. The most effective here is the gastric bypass operation.

Now one of the problems of course is you are creating a patient for life, because certainly, with a bypass operation, you need to follow and monitor that patient for a long period of time. But having said that, [slide 24] these are the results from the first two years of the SOS study and these are, remember, patients who’ve lost between 30 and 40 kilograms in weight. The blue, which doesn’t project very well, is the improvement. At two years there was 40% of patients who were previously hypertensive were no longer hypertensive. So diabetes: there’s about 60% have come off their tablets, and all the other parameters were improved. The total cholesterol at eight years had improved as well. At eight years, all of these benefits have been sustained apart from, interestingly, the blood pressure, which seems to have now returned to its previous level. But there are considerable benefits from surgery. So although it seems quite draconian, it does work and is effective. Having said that, of course, [slide 25] it is only suitable for a very small number of people. I’ve listed the criteria here, and I think it’s important that those with established complications, that the individual understands the mechanism and importantly, there’s no contra-indication to the general anaesthetic or the surgery. Remember, the larger you are, the more hazardous any operative intervention, although most of the operative interventions now is done laparoscopically. The bigger you are, the more difficult it is to achieve this.

[slide 26] I’m now going to just simply reflect on the changing trends at a specialist clinic. I’m one of the few individuals in the country who runs an obesity clinic. We see in excess of 400 new referrals each year and indeed, unfortunately, we have a waiting list, because there are so many of them. But look at the body mass index of the patients attending the clinic since we started in 1980. It’s increased from 35 to a mean now of 50 plus. Importantly, also, at the outset it was largely women who were referred. Now that ratio is changing and that’s because the prevalence has increased of the super obese in the UK. Many of these young individuals have major problems [slide 27] and we’ve become much more of a specialist centre for people with major problems.

So what about successful management from our clinic? Diet and exercise: this is an audit undertaken by Milaker, who’s in the audience. Over the past year, 8.2% weight loss at one year. So, reasonable, but the range is a gain in weight from attending the clinic. They default very early to a loss of about 24%. This is their presenting weight. So diet and exercise is very effective, even in these very large individuals. Drugs: well, it’s a mean of 9.5% weight loss at one year. But again, a range of gain on weight. A non-responder to a 17% loss. So, respectable in a clinical setting, and remember, these are people referred because they had an inability to lose weight. But finally, look at surgery, and it’s a relatively small number of individuals who go on to surgery. 16% weight loss at one year. That’s 16% from their presenting weight, and it’s 26% at two years. But I must remember or recall again that these are patients now for the longer term.

So if we return then, [slide 28] about improving treatment and management programmes, and as it’s been said, it must be an integrated or joined-up approach. How should we address this? Well, firstly, I do hark back to our president, our prime minister, that it’s education, education and education. It is very important that not only should we educate the population at large that over-nutrition may be a disease, not simply a cosmetic problem, but just as importantly - and I think this harks back to last presentation - that it is important to educate health professionals, and that starts at the undergraduate and moves into the post-graduate education, the continuing professional development, about the problems related to over-nutrition as well as under-nutrition. Then if we look at the sort of step-wise approach, [slide 29] an integrated approach for improving treatment, it should start within primary and the care in the community. Ian Campbell will be talking about this further in a moment. In secondary care I think we have to get our act together in relation to clinical government and the development of multi-professional teams to identify those at risk from being either over- or under-nourished, and methods to intervene.

Finally, I do emphasise the importance of developing specialist centres, more specialist centres, probably on a regional basis, to manage these people with what we call "super-obesity": the very large individual, the young, very large individual, using again a multi-professional or multi-disciplinary team and possibly considering surgery for certain individuals. Thank you.

DR WILLIAM DIETZ: Thank you, Peter. Our next speaker is Dr Ian Campbell, who is Chair of the National Obesity Forum, who will also be discussing improving management and treatment.

DR IAN CAMPBELL: [slide 1] Thank you very much indeed. I’ve been told to keep very tight to my allotted 20 minutes otherwise there’s a trapdoor opens up under my feet, and so just in case I don’t get to thank you at the end, it’s been a pleasure.

I want to talk about obesity as I see it. I want to try and explain to you what motivates a primary care physician to be involved in obesity management. But before I say anything, I really want to thank the families from the Carnegie Fat Camp who gave their story first, because for 24 hours now we’ve been surrounded by the absolute best in the obesity world, the best speakers, the most learned people, and it’s fascinating. But really, there’s nothing quite so compelling as true stories, is there? So my thanks to you. It’s that’s sort of thing that really motivates me to try and make changes in my practice and in those other physicians with whom I come into contact.

You’ve seen all the levels of obesity. We know how bad it is. The important thing on this slide to note is not just how much overweight is going up, but the times here it’s going up, the rapidity with which it’s going up and the fact that it shows no signs of stopping. We in general practice: doctors, nurses, dieticians, we’re saturated already. But what we can see here is an increase in our workload that we either acknowledge or we don’t. But it’s definitely there.

[slide 2] And of course, we’ve been speaking about children - a much neglected part of our problem - but the figures, however we choose to calculate them, I think what’s inescapable is the fact that the prevalence of obesity in children is going up. And again we’re storing up great problems for the future here. The National Obesity Forum, which I represent, has been concerned enough about this to try and develop, with the assistance of the Royal College of Paediatricians, some guidelines for the management of obesity in children. So that should be forthcoming.

[slide 3] What does obesity mean? It means too much weight, to the detriment of your health, and we define it traditionally as body mass index, which has been very useful. For years I’ve been trying to work out what body mass index was, then when I sussed it out I tried to explain it to my colleagues. So, just keeping it very simple, if your BMI’s less than 25, you’re considered to be of normal weight. Above 25, it’s overweight. Above 30, you’re clinically obese and above 40, morbidly obese. So that’s how everyone’s trying to calculate obesity in this country and around the world. The problem is patients don’t really understand it and doctors don’t understand it. You don’t stand on your scales at home and it gives you your BMI. It gives you your weight.

[slide 4] What we’re increasingly realising is that a waist measurement, the simplest thing to do, is a better predictor of cardiovascular risk and a better measure of the dangerous fat, the visceral adiposity, that actually causes the problems. So I’m very much keen with my patients to look at waist circumference, and it’s something I ask my colleagues in primary care to do also. With men you’re looking at a waist size greater than 102, and with women a waist size greater than 88. And believe me, we’re not talking about your belt size, any of you blokes out there taking consolation that you’re still in your 32 size belt. It’s the bit hanging out over the top we’re trying to measure.

[slide 5] Because we do get complicated. I mean, I’m supposed to know about this thing. My sister-in-law in California, when I was out there in the summer, perhaps at the wrong time of the evening though, she asked me to calculate her body mass index. I got a piece of paper and a pen and, well, I’m not saying she was obese but she did have a bit of a tummy on her. And I calculated her BMI and it came out at 63. I thought, "No, no, no. Sorry, Yvonne". So I turned the paper upside-down and did it again and it came out at 17. So it’s difficult. Waist measurement is much more simple. We need to start using it.

[slide 6] I’ve got to go close to read this. Right. This advert says, "A hazardous substance is stored nearby. It’s the excess fat packed around your middle, fat that increases your risk of heart disease and other serious illnesses such as diabetes. A good reason to start a waist disposal programme today."

[slide 7] We know what causes overweight and obesity - you eat too much, you don’t exercise enough. But you know, if it were that simple, I don’t think we would be here. I don’t think our patients would be coming to see us. It is not that simple. If you’ve ever tried to lose some weight - and if you haven’t done, I challenge you to do it - put your money where your mouth is, so to speak. Try it. Aim for half a stone, lose it and keep it off and see how hard it is. It is not at all easy. There are so many pressures: environmental, social, physiological, therapeutic. All these things, which conspire that make us put on weight. It is not at all easy. We need to start getting rid of the myth that the obese patient is sitting at home, watching football and eating pretzels. No, sorry, eating cream cakes. It’s a myth. It doesn’t happen in the vast majority of cases.

[slide 8] So why should it interest my colleagues higher up within the health service, those that control the purse strings? Quite simple: because of the cost. You’ve seen these figures, but just look at them again. £0.5 billion for the direct costs of obesity - not treating it but dealing with the consequences of it - £0.5 billion. The indirect cause of disability, the loss of employment, the fact we are clinically obese when we retire, you have a less financial net worth than someone who’s not obese. Work that one out. So it has huge impact on our nation. Totals £2.6 billion per year and these figures are out-of-date already.

[slide 9] This is my job. This is what I do for a living. I look after people with a whole different range of diseases. I’m a jack-of-all-trades and master of none. I need to know a little bit of everything. So how does obesity impact on my working life in general practice? It increases the number of strokes that my patients suffer. It affects their cardiovascular risk, heart disease, heart attacks, heart failure. It causes diabetes. 90% of my diabetics are overweight. Osteoarthritis: much overlooked. The greatest cost of obesity in Australia is not heart disease, it’s not strokes, it’s osteoarthritis, with people who wake at two in the morning in pain that we don’t know about. Cancer. Obesity is the biggest preventable cause of cancer after smoking. Hormonal abnormalities. If you’ve ever had to work with someone who’s infertile, a woman who’s infertile and the distress it can cause. Yet, most of them are overweight, and we also know that if you can reduce the weight by 10% you can increase the fertility 14-fold. So even fertility problems have a weight bearing. Gallbladder disease and respiratory disease, sleep apnoea. You work with people with a BMI greater than 40, you can hear it in their voice, the effect that it’s having on them. It is a disease, it causes a multiple of pathologies and really I so much believe it’s a distinct disease in its own right, but it has such an effect in so many other areas that it’s inseparable from them all.

[slide 10] I sometimes think this is the most important slide of all that I want to show you, simply because, again, I think these numbers are incredible. We’re talking about mortality here, not just quality of life, but a 10% fall in weight loss, which we can achieve in clinical practice, achieves a 20% fall in total mortality. That’s a lot of people. Blood pressure drops, fasting glucose drops. You can stop your diabetics needing medication, if you work with them and give them the time, and improve the lipid profile. We strive for this in primary care. We have heart disease clinics, we have diabetic clinics, we strive to achieve this. And yet, in the main, we ignore the underlying cause: overweight and obesity.

[slide 11] The National Obesity Forum was set up three years ago to try and address some of the difficulties we have in primary care, because we knew that people were doing good work, we just didn’t know who they were, where they were and what they were doing. It’s true that the provision for health services for overweight and obese people in the health service is extremely patchy. But that doesn’t mean to say there are not good people out there working very hard, often at their own time and expense to improve the services they can offer. The National Obesity Forum wants to promote this and encourage best practice. [slide 12] (Most people are thinking I wish my doctor looked as nice as that.)

Average general practice list: 2,000 patients. It’s too many, but that’s roughly how it is. 800 of my patients must be overweight, 320 must be obese and 60 must be morbidly obese. It’s a huge problem. I can’t deal with all this on my own. When faced with a patient, I have to respond. I have to try and provide weight management services for them if that’s what they wish. But I can’t do it on my own. We need to make use of this vast multi-disciplinary approach that’s been so evident over the past two days.

[slide 13] I want to talk about men, because we’ve talked about children, we’ve talked about socially deprived people. Another group of patients that we are pretty poor with is men. There’s a fascinating study, a bit light-hearted, but I think you might identify with it. 2,000 men interviewed, interviewed about their trousers, okay? - About their trouser size. What was fascinating was that the majority of men underestimate their waist size. It’s a bit dark here so I can’t see the guilty looks on the men’s faces, but I guarantee if you look at the bloke next to you, he’s there, right? You get up in the morning, you get your trousers ready and you’re 35 and you think you’re still 25 and you’re doing this: your stomach’s going in, you’re tightening your belt because it’s going to get to that notch you’ve always used. Yeah, we all do it. What’s even more fascinating is that when they did this hologram image of these men, only 40% could identify with themselves. They couldn’t recognise their shape, because we have a distorted image. Men are not that good at appreciating the damage they’re doing to their health. But they did appreciate that the stomach was the bit they hated the most. [slide 14] So if we’re going to direct services towards men, we need to think about what it will be that turns them on, to help them to be encouraged to lose weight. In my general practice, less than one in five of the patients in our obesity clinic are men. In the commercial world it depends who you talk to, but it’s certainly a very low number. Maybe as low as 1% of the people that go to commercial slimming groups are men. And yet we know as many are overweight and obese.

[slide 15] So what’s the problem? The problem is very complex. But let’s just start looking at the general practitioner, who is subject to the same prejudices that you and I have suffered. If you ask a simple little child, "Would you rather play with a child who is obese or a child who is handicapped?" they will prefer the child who is handicapped. It is an inbuilt prejudice already developed at that stage and we in the medical profession, I am sad to say, are subject to the same pressures. So we don’t really think it’s our problem. We don’t have the time, we don’t have the knowledge, we’ve never had any training on how to deal with it, as some of our patients have detailed for us this morning

And this idea that you can treat something and it goes away is a wonderful thing in general practice. But obesity doesn’t work like that. It keeps coming back. If you’re going to do anything significant about it you have to accept that before you even start. It’s a chronic disease. And this frustration that what goes down must come back up, this yo-yo effect, has driven a lot of people away from any interest in weight management. So these are some of the problems we have to address. But we do know that training produces results. A study in North America with primary care physicians took them away for two days, taught them how to handle obesity and they went back into practice and what was clear was that both the quality and the quantity of their interventions with obese patients rose quite sharply.

[slide 16] We need to try and work out what success means. It’s not acceptable to aim for this ideal weight that our computer systems will throw up in front of us when you put up somebody’s BMI. It doesn’t work like that. We’re talking 5 -10%. Yes, I wish it was more, but realistically that’s what we can achieve. If you can just see where this sort of weight maintenance leads us. We all know that people can lose weight over a time period: 6 months, 12 months, whatever, and then they do start to put it on, and people can become very despondent during this period. But what we need to recognise is that for some patients, even weight maintenance would have been beneficial. And given the natural course of events, the inevitable weight rise that they would see is still a net weight loss, which could have very tangible health benefits.

[slide 17] The National Association of Primary Care did a survey on primary care health workers to see what was interesting them and how they thought they could improve the services within primary care. Very quickly, just points to take out. The vast majority thought that treating people with a BMI greater than 25 was important. [slide 18] They thought that funding was crucial. 75% wanted more funding. Guidelines on weight management were important. They wanted more added nursing resources, they wanted easier access to ancillary services and they wanted a consensus on obesity management, a consensus on practice, a consensus in the PCT and a consensus nationally. [slide 19] Who wanted practice guidelines? 29% only. Are you aware of national guidelines? Only 22%. 1/5 of practice, were aware that there are national guidelines from the Royal College of Physicians, the fine guidelines of the National Obesity Forum. They are unaware of them. The message is still not getting out. [slide 20]

Training was identified as being absolutely crucial if we were to improve the situation. Local training. Not a two-day conference in London - local training where they work. There are three or four general practitioners here, three or four physicians here; they don’t come to big conferences like this. We need things locally to us. The local training for GPs, local training for nurses and access again to this ancillary help. People do want more, but they want it locally and they want it provided in a way so that they can access it and deliver it in a way that’s appropriate to them. But there is a desire there to improve things.

[slide 21] Okay. Who does this make you think about? Who is it? Is it the patient, lying in his chair at home at night, eating too much, watching too much TV? Is that who is to blame for the problem? Or maybe some of you thought it was the GP? Okay, I got a laugh. Right. He was the GP who’s done his bit: he’s had his diabetic clinic today and he’s measured a few blood pressures and he seems quite happy with himself. He thinks he’s done his job. Or maybe it’s the people that control the purse strings in the health service. They think we’ve got enough. "Well, you know, they can keep beefing on about it, but really we’re quite happy, we’ve done our bit". Maybe it’s politicians. They think they’ve got us where they want us. I don’t know. You draw your own conclusion.

[slide 22] So what are we going to have to do? Clearly, things are going to have to change. I am heartened by the sheer volume of different interest groups here today and yesterday, and bearing in mind that these are the motivated people who are here. It doesn’t represent what’s happening outside. What we need to do is try and change the attitudes of our colleagues in health and education and retail. We need to change their attitude. It’s happening too slowly. All of this fantastic work that we’ve been hearing about is too fragmented. I don’t know what you’re doing, you don’t know what I’m doing and we’re not really working together. It’s a bit of a cliché today, but it is time to join forces to tackle obesity, and we need to work together to make sure that things actually change. And it’s time to stop talking about it. It’s time to start doing things about it. I think it’s absolutely crucial.

[slide 23] Last but one slide. What I’m suggesting is that we try and develop a national institute - call it what you like - but a national institute for obesity management that incorporates all the different disciplines we’ve heard for these two days, because every one is essential, is part of the solution. A national institute of obesity management that has a piece that doesn’t talk, but actually makes decisions and disseminates information that we are obliged to follow. Sound too draconian? I think unless we do something like this all we’re going to do is keep talking about it. So we need to see recognition from those experts in the field: the ASO, the International Obesity Task Force, the Department of Health and education media, NOF; all these groups need to have a say in what’s going to happen. All of you here represented here and the patient groups, and the NHS has to start prioritising for all the good reasons we’ve heard already today and yesterday. And I think we should look very closely at partnership with the private sector. We’re doing it in Paris. We’re sending patients to Paris to have eye operations. Why are we not working locally? We talk about working the PCTs. I’ve been on a PCT board for four years now and we’ve achieved next to nothing. This concept that I’ve heard today about PC -- a great opportunity with the advent of PCTs and local control, it’s not happening folks, believe me, it’s not happening. It’s all talk. It’s time to stop the talking and start doing the doing. [slide 24] Thanks very much.

DR WILLIAM DIETZ: Now, we have time for several questions.

QUESTION FROM FLOOR: OFFLINE RESPONSE particular (UE) in Africa (UE) name. We are (UE) for the (inaudible) Society about a new drug, which was rediscovered by the (UE) and sold to (UE) And the origin is from a cactus from the borders in South African continent, I think, and that has been -- I don’t know if pre-clinical trials has been done and the (UE) has been approved of, but what -- I was told that it has got side effects, serious side effects like other drug, so your invaluable opinion about that drug, sir.

DR WILLIAM DIETZ: This, I believe, is the drug that was used by the Kalahari bushmen. But I’m not sure that it’s on the market, is it?

PROF PETER KOPELMAN: No, it’s not. I mean it’s, "under development", but I think it would be too premature to actually make any comment.

DR WILLIAM DIETZ: It’s in development.

Other questions? Yes, in the centre here?

QUESTION FROM FLOOR: You mentioned about joining forces - which is what this is all about - for obesity. In terms of smoking cessation, we’ve got organisations like ASH that lobby, which are not necessarily statutory organisations at all. I feel as though there isn’t anything like that out there dealing with obesity. We’ve got alliances in different regional areas that like to tackle fat and consumption and so on. Surely we need more than just the joining forces that you mentioned?

DR IAN CAMPBELL: I think there are lots of people who are trying to apply pressure in different directions. The difficulty I have is that the majority of them are relying on goodwill, on charitable handouts and working in their spare time, and nobody’s really got the bit between the teeth to really go for it and make a big noise. We’re doing lots of little things, all very constructive things. But what we really would like to see is all these groups working together and being supportive. By suggesting there’s a national institute, I’m really implying that the government should be funding it, and not it being reliant on outside sources.

PROF PETER KOPELMAN: I think it’s a very good point, because we’ve heard how public health is going to be put very firmly in the primary care trust and one would anticipate that public health would actually lead such an initiative. But at the moment it’s very much a fledgling organisation. It’s trying to bring people together. There’s also other -- I mean, TOAST is an example of a patients’ led organisation. It’s bringing people together at a local level, which is the challenge.

DR WILLIAM DIETZ: Is there another question in the back centre?

QUESTION FROM FLOOR: Thank you, and just in relation to that last point. I mention the UK Public Health Association, which is a charity, who I know wrote a huge document on food and family, the whole wider approach to food and family, I know have also applied to this particular document and been to see the government as well. But they weren’t invited to this conference. But I know they would have liked to have been. But I think the Chair would have said a lot more had he been here but I think, a bit of confusion when it was, and I don’t think anyone from here is actually present at the moment. But there is quite a big lobby and particularly the government approach and looking at regulating the food industry and children’s advertising.

QUESTION FROM FLOOR: John Gareth. Dr Campbell mentioned the question of co-operating with the private sector, particularly in respect to slimming clubs and things of that sort, which seems a very good idea and there are people here from commercial slimming clubs. The question that I’m asking is, why is it not reasonable (indeed, it is possible, because we’ve shown that we’ve done it) to set up in each health district, non-profit-making but self-financing slimming clubs, led by a registered dietician where people pay a modest sum, because it’s non-profit-making, go along to these clubs? It’s been done in the Harrow Health District when I was there. We published the results of the first 10 years of this during which over 1,000 people were seen. This has not yet been mentioned as an option and it seems to me one, which is possible and effective and doesn’t require large inputs of money from the NHS, in fact doesn’t require any input of money from the NHS. The clubs were held in the evening in, for example, school clinics. They were local authority premises, which were available in the evenings because they are not being used between 7pm and 9pm in the evening.

DR IAN CAMPBELL: I think it’s a very valid point. I don’t know why it’s not happened before. I think it’s probably more difficult to set something up in a commercial vein than it initially appears and we’re perhaps not very astute at that within the health service. But the concept certainly is appealing, because if these commercial agencies do work, then plainly, if it’s a cost-effective route, then we should utilise it. And I can only think that it will prompt some people to think about it.

DR WILLIAM DIETZ: One last question, yes, from the centre?

COMMENT FROM FLOOR: Hello, it’s Mary Morris. We obviously have a network right throughout the UK and we feel very strongly that we have that expertise that training is already in place. And we believe that there is a cost-effective way of tapping in, and this joined forces approach. We think there is plenty to be talked about. One sad reflection from these whole two days, I believe, is that we are represented here as delegates but we’re not asked to present our work and our results and our evidence within our own organisations, actually on the podium. Thank you.

DR WILLIAM DIETZ: Thank you for that comment. Thank you audience, for your attention, and thank you Peter, Ian and the Drysdales, Nixons and Packs. Thank you very much for this session.