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
21st 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.