Joining Forces to Tackle Obesity, 21-22 January 2002

 

Transcript : Improving Management and Treatment

 

Speaker

Dr Ian Campbell

GP, Chairman of the National Obesity Forum

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 which 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 by how many times 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 the 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 very shortly.

 

[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 for it to give 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 in that you’re still in your 32 inch 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, Yvette". 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 to 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 that if we are clinically obese when we retire, we have less financial net worth than someone who’s not obese. Work that one out. So it has a huge impact on our nation. It 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. Gallbladder disease and respiratory disease, sleep apnoea. If 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 multiple pathologies and I 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, 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 in 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 men as women 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 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 in 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 and the inevitable weight rise that they would see anyway, it 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 their 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 in the 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 practices were aware that there are national guidelines from the Royal College of Physicians, and 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. 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 going 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 and is part of the solution. A national institute of obesity management that doesn’t just 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, the National Obesity Forum; all these groups need to have a say in what’s going to happen. All of you 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 with 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 PCT’s -- 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 their 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.