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O VERWEIGHT AND OBESITY IN ADULTS IN GENERAL PRACTICE Validated by CEBAM under number 2006/01 Authors: Paul Van Royen, Hilde Bastiaens, An D'hondt, Chris Provoost, Wout Van Der Borght


Patient input and consideration by the GP

Recommendations for good medical practice are guiding as support and guidance when making diagnostic or therapeutic decisions in general practice. They summarize for the general practitioner what is scientifically the best policy for the average patient. In addition, there is the agenda of the patient, who is an equal partner in decision-making. Therefore, through clear communication, the patient's question must be clear to the general practitioner and the general practitioner must inform the patient sufficiently about all aspects of the various policy options. It is therefore possible that the general practitioner and patient together make a different best choice in a responsible and reasoned manner. For practical reasons, this principle is not addressed repeatedly in the recommendations, but is explicitly stated here.


Introduction

Overweight and obesity are one of the most important health problems in our Western society. In the age group of 35 to 59 years, more than 28% of women and 49% of men are overweight. Obesity occurs in 13% of women and 14% of men ( 1 ). The prevalence of severe obesity is approximately 5-10% of the total population. Overweight and obesity become more common with increasing age ( 2 ).


What?

Obesity is the result of a long-term energy imbalance, where daily energy intake exceeds energy expenditure. Energy balance is modulated by many factors, including metabolism, hunger, dietary habits, and physical activity ( 3 ).

Obesity is associated with a significant number of complications and comorbidities ( 4 ), such as (non-insulin-dependent) diabetes mellitus type 2 ( 5 ), lipid disorders ( 6 ), metabolic syndrome, cardiovascular diseases (hypertension, angina pectoris and coronary diseases ( 7 ), varicose veins, thromboembolic diseases, CVA), gallstones, liver cirrhosis, cholecystitis, gout, skeletal abnormalities (arthrosis, pes planus), intertrigo, physical complaints such as joint pain, dyspnea, heartburn, sweating, increased risk of cancer (prostate and colon in men and breast, liver, gallbladder, bladder, uterus (cervical) and ovaries in women) ( 8 ) and sleep apnea ( 9 ).


Consequences of complications

All of these complications increase mortality, hospitalizations, and overall health care costs ( 10 ). Based on the type of obesity, the physician can estimate the risks fairly accurately (see Clinical Research ). Non-abdominal obesity (pear shape) usually leads to mechanical complications, such as osteoarthritis, gout, varicose veins, intertrigo, and venous insufficiency. Abdominal obesity (apple shape) is more likely to result in cardiovascular and metabolic complications.


Effect of treatment

The beneficial outcome of obesity treatment can be measured at different levels: the percentage and/or absolute amount of weight loss, the avoidance of complications and biopsychosocial well-being (see Clinical Research ).

Losing weight is indeed associated with an improvement in risk factors. Already with a weight loss of

10% or approximately 10 kg, a decrease of 10 mmHg in systolic and 20 mmHg in diastolic blood pressure can be observed, as well as a 91% reduction in symptoms of angina pectoris, a 33% increase in exercise tolerance, a 30-50% decrease in fasting glycaemia and 15% in HbA1c, a 10% decrease in total cholesterol, a 15% reduction in LDL, a 30% decrease in triglycerides and finally an 8% increase in HDL ( 11 ). Based on this, one can expect that the mortality risk will decrease.

Whether a decrease in body weight in itself has an effect remains the question. In practice, permanent weight loss is often difficult. Mortality does decrease with a decrease in body weight, when there is comorbidity such as type 2 diabetes or ischemic cardiovascular diseases.

In elderly patients with obesity (over 80 years of age), initiation of treatment should be weighed against quality of life and perceived benefit ( 12 ).


Role of the GP

Obesity can be considered a chronic problem. Retrospectively, it often appears that people who are overweight later in life, already experienced a significant weight gain in young adulthood. This underlines the importance of preventive measures and education.

The general practitioner is confronted with problems of overweight and obesity almost daily ( 13 ). Out of every thousand consultations in a general practice, about twenty are directly related to the problem of overweight. Each year, there are about fifteen new cases of obesity per thousand men and 26 per thousand women. The highest incidence is in the age group 45-64 years and in the lower social class ( 14 ).

The general practitioner can play a central role in identifying overweight and obesity, including by regularly measuring the body weight of his patients ( 15 ). This can be incorporated into routine schedules for monitoring hypertension, diabetes, osteoarthritis, heart disease, CARA, contraception, sports examinations and the like. By recording the weight and its increase or decrease compared to the previous measurement, a good overview of the course over time is created. In this way, the doctor can continue to motivate the patient and take on preventive tasks. Such an active policy is particularly important for the 20-30 age group. The right information about healthy eating and lifestyle habits can prevent many problems resulting from overweight.

It is important that the GP can recognise and refer obese patients due to an eating disorder – more specifically bulimia nervosa and binge eating disorder ( 16 ).

Once the diagnosis of overweight or obesity has been made, and provided that the patient is sufficiently motivated, it is the GP's task to initiate and monitor a phased treatment. To this end, he can establish a collaboration with other primary care providers, primarily with dieticians.

In obese patients who have already made several unsuccessful attempts (treatment resistance), the GP should primarily detect possible complications at an early stage and treat them adequately (tertiary prevention).


Questioning

This recommendation concerns the diagnosis, treatment and follow-up of adult patients with obesity in general practice. Based on the available scientific literature, an answer is formulated to the following clinical questions:


How can the GP distinguish between obesity with and obesity without an eating disorder?

How can the GP determine the morbidity and mortality risk in an obese patient?

From what Body Mass Index or BMI (and other associated parameters) should a patient be treated?

With which therapeutic agents can the GP achieve a beneficial effect in an obese patient in the short and long term (at least one year or longer)?

Does it make sense for the GP to advise a treatment approach for a patient without risk factors?

This recommendation does not deal with the diagnosis, treatment and follow-up of childhood obesity, nor with the approach and treatment of obesity in eating disorders. Other causes of weight gain are also not discussed in this recommendation ( 17 ).

There is currently a lack of data on quality indicators regarding the management of obesity, including the process and outcome of obesity treatment. However, this recommendation is a good reference point and an incentive to improve the quality of care for obesity patients.


Definitions

Obesity can be defined as a condition of excess accumulation of body fat, compared to the norm for age and sex. Direct measurements of total body fat are difficult to perform in practice and not always reliable. Therefore, indirect methods are used, such as the Body Mass Index (BMI or Quetelet index) ( 18 ):



weight in kg

BMI = ———————

(length in m) 2


Overweight is defined as a BMI of 25 to

29.9 ( 19 ). We speak of obesity from a BMI of 30. Above that, there is an additional risk of morbidity and mortality. From a BMI of 40, we speak of morbid obesity.

As a risk factor for health, not only the degree of overweight is important, but especially the type of obesity, in other words the place in the body where the excess fat is located. This plays an essential role in the prognosis. For example, abdominal fat deposition ('apple shape') is an important risk factor for the development of diabetes and cardiovascular diseases, among other things. Abdominal obesity entails more health risks than when the fat is on the hips and thighs ('pear shape') ( 20 ).

The doctor can determine the type of obesity in adults by measuring the waist circumference (at the level of the navel). We speak of abdominal obesity when the waist circumference is =88 cm for women and =102 cm for men.


Intake

Presentation of the weight problem

The overweight or obese patient can present to the consultation in different ways:


Often the patient comes to the consultation with his 'weight problem' as the only complaint. Often it is psychosocial circumstances that form the motivation to seek help. Sometimes it happens that an obese patient is sent to the doctor by his environment, without being motivated to lose weight himself.

The patient may consider himself too fat, while objectively he is not or only slightly so. Usually it is women, and in rare cases also men, who ask for help to lose weight, which fits within the exaggerated socio-culturally determined slimness ideal.

There are also patients who come for consultation for something else, but for whom the GP can immediately see that there is a problem of overweight or obesity. These patients do not seek help at all or feel inhibited to formulate the request for help.

When measuring and weighing his patients, the family doctor can detect a clear increase in weight. In this case, it is important that he points this out to them.

Rarely does the obese patient consult his doctor with complaints that are directly related to his excess weight (fatigue, listlessness or shortness of breath). The problem of weight gain is often presented in a covert manner. Obese people usually have a long history of sometimes striking discrimination and hurtful remarks from strangers or previous caregivers. It is therefore not at all surprising that they adopt a defensive attitude ( 21 ).

For the physician, too, the complaint of 'getting fatter' or 'being too fat' can have very different meanings. One's own standards and values ​​play an essential role in the approach to overweight ( 22 ).


Patient motivation

At the beginning of the consultation it is very important that the GP finds out to what extent the patient is motivated to change. After all, tackling weight problems requires a great deal of effort from the patient (diet, lifestyle changes, medication, etc.). Some central questions from clinical psychology can help with this ( 23 ):


How important do you think it is to lose weight? What needs to change for you to find losing weight more important?

How important do you think it is to change your eating habits/lifestyle? (ask about motivation)

If you were to decide to lose weight, how confident would you be in yourself to succeed? What would need to change for you to have more confidence to lose weight successfully? (question about self-confidence)

These questions are also very suitable to encourage the patient to evaluate his or her own health status and, above all, to reinforce his or her self-motivating statements ( 24 ).


Initiate behavior change

Several theories from health psychology have provided motivational models (for example, the 'Health Belief Model' by Taylor, 1990) ( 25 ). A very well-known and particularly useful model is that of Prochaska & DiClemente (1986). This model describes motivation in delineable stages. These stages offer the physician an excellent aid in estimating the level of motivation of his patient. Moreover, it gives the physician indications to choose the appropriate intervention tailored to the individual patient (see Table 1).




Table 1: Stages of behavior change.

Phase Feature Willingness to take action Possible intervention

Preliminary phase A person at this stage does not consider change at all and does not see his behavior as a problem (he is under-informed about the consequences or burned out by the many attempts?) The patient does not plan to take action in the near future (six months) Increase insight through personalized information

Contemplative phase The person recognizes the problem, but is still very ambivalent about change. He is more aware of the advantages of change, but also sees many disadvantages The patient is thinking about changing, but in the near future (six weeks) Discuss the pros and cons of change and increase the patient's confidence to achieve the necessary behavioral change

Decision phase The patient makes a plan. He may already be experimenting with small changes. There is still some ambivalence The patient prepares for change, usually within a month Create a concrete plan with a realistic goal and support small changes in the patient

Active phase The person at this stage specifically and openly changes his lifestyle. This behavior is clearly observable The patient is committed to an action plan Refer for nutritional advice and behavior change and offer self-help materials, medication, etc.

Maintenance phase The new behavior takes a place in the person's life. Changes in eating behavior and weight loss have occurred. Maintaining weight becomes a new goal The patient is committed to an action plan Teach the patient problem-solving behavior so that he learns to anticipate difficulties

Relapse phase Relapse is always possible and is the rule rather than the exception The patient goes through the stages of change on average six times before a stable change is achieved Support the patient's self-confidence and provide insight into the causes of relapse


In order to motivate a person to change, it is important to address him in a way that is adapted to the motivational stage he is in. In this model, motivating does not mean confronting the patient with the consequences of his behaviour ( 26 ) or convincing him to change his behaviour. It comes down to helping the patient evolve towards a more active phase of behavioural change. Patients in the first motivational stages (pre-contemplation and contemplation) in particular are a great challenge for the GP. There is little point in prescribing a diet or medication to a person in the pre-contemplation phase ( 27 ). For patients in the decision-making phase, motivating them to achieve a feasible (weight) goal becomes the most important, but equally difficult task for the GP. Initiating this motivational process is best done in several consultations.

For some patients, the support of the environment (partner and other family members) is of great importance. The doctor can also encourage them to adopt a positive, supportive attitude towards the person who wants to lose weight.


Diagnostic phase

Anamnesis

For the patient in the decision phase with a clear request for change, the GP can apply the classic consultation model: diagnostic phase with targeted information, clinical examination and therapeutic phase. He first collects a number of anamnesis data:


How much did the weight increase, over how much time ( 28 )?


How is your appetite and what are your eating habits? It is important to determine whether emotional or external eating is involved. Emotional eating is a response to negative emotions (disappointment, boredom, and tension). External eating is primarily a response to external stimuli, such as smell, tasty presentation, and easy availability of the food ( 29 ).

Do you deliberately eat less to avoid getting fat? And how often do you turn down food and drinks offered to you because you want to think about your weight ( 30 )? (dieting behavior)

Do you sometimes eat abnormally large amounts of food in a short period of time? If so, do you feel that you are no longer in control of your eating, with feelings of guilt and anxiety afterwards ( 31 )?

What are your lifestyle habits (do you smoke, drink alcohol, use drugs, do you play sports and exercise) ( 32 )?

Are you taking any medications?

Have you already been treated for obesity? What were the previous treatments? Have you already made some attempts yourself?

Are there other complaints such as fatigue, listlessness or shortness of breath?

We repeat that the correct assessment of the nature of the eating behavior is of great importance. The physician must be alert to the existence of a binge eating disorder (see box) or bulimia nervosa.

It has been shown that binge eating disorder is strongly related to the severity of obesity and the presence of large weight fluctuations. Obese patients with a binge eating disorder also have psychological and psychiatric problems, especially mood disorders (depression), compared to obese patients without this eating disorder.

If a diagnosis of binge eating disorder is made, the doctor preferably refers the patient to a psychiatrist or psychologist who specializes in the treatment of eating disorders ( 33 ).



Diagnostic criteria for binge eating disorder

I.

Recurrent episodes of eating:

1 Eating an excessive amount of food in a limited period of time (e.g., two hours).

2 Feeling of loss of control or lack of control over eating (feeling that one cannot stop eating or control how much one eats).


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II.

The eating episodes are further associated with three of the following criteria:


Eating much faster than normal.

Eating until one feels uncomfortably full.

Eating large amounts of food while not feeling physically hungry.

Eating alone because one is ashamed of the quantity.

Feeling disgusted with oneself, depressed or very guilty after overeating.

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III.

There is a distinctly unpleasant tension about this binge.


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IV.

The binge eating occurs, on average, at least two days a week for six months.


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V.

The binge eating is not associated with the regular use of maladaptive or ineffective compensatory behaviors (vomiting, purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa ( 34 ).




Clinical research

It is necessary to first objectify the weight gain ( 35 ). The doctor can use the clinical examination to evaluate the damage that the excess weight has already caused to the patient's health.

To this end, the family doctor determines the degree of weight gain. He measures the body weight (without shoes) on a good scale and the height in cm. On the basis of this, he calculates a BMI index. This can be done using the previously mentioned formula or a nomogram (see figure 1).




Figure 1: Nomogram for the determination of the Body Mass Index.




In order to know the morbidity and mortality risk, the general practitioner determines the type of obesity ('apple-shaped' versus 'pear-shaped'). For this purpose, he measures the waist circumference (see table 2). Other diagnostic techniques are not useful in the general practice ( 36 ).

A general clinical examination further investigates the cause of the overweight and whether there is already an impact on the physical condition: blood pressure measurement, general inspection of the skin, heart and lung auscultation and palpation of the thyroid gland.




Table 2: Classification based on waist circumference.

Increased risk Greatly increased risk

Men =94 cm =102 cm

Women =80 cm =88 cm


Additional research

Additional investigation is of no use if the BMI is <30, unless there is an increased cardiovascular risk based on personal or family history and/or clinical examination (waist circumference).

In case of increased cardiovascular risk and/or obesity (BMI>30), laboratory testing is useful, with the following determinations on a fasting blood sample: glucose, cholesterol (total and HDL) and triglycerides ( 37 ). If there are additional risk factors and/or comorbidities, the approach to overweight or obesity will have to be much stricter (see further).


Treatment of obesity

Phased treatment

The approach to obesity is very difficult in practice and is only taken up by a limited number of doctors ( 38 ). It is therefore not surprising that many patients try out various options: slimming advice from a GP or dietician, slimming courses via commercial organisations such as Weight Watchers, eccentric slimming diets such as the sherry cure, cabbage soup cure, etc. There is also a growing market for all kinds of specific products, such as substitution products for energy-rich foods and meal replacements ( 39 ).

The approach to obesity in general practice is individual and takes place in stages ( 40 ). The three pillars of treatment are: diet, behavioural and exercise advice ( 41 ). Pharmacotherapy or surgical treatment may also be considered (see Table 3).




Table 3: Selection of treatment strategies according to BMI category, as a function of other comorbidities or risk factors ( 42 ).

BMI category (kg/m2)

Treatment 25.0-26.9 27.0-29.9 30.0-34.9 35.0-39.9 =40.0

Diet, behavioral and exercise advice With comorb. With comorb. + + +

Pharmacotherapy With comorb. + + +

Surgery With comorb. +


The + indicates that a particular strategy is indicated, even without the presence of other comorbidities or risk factors.

With comorb. = With comorbidities



Research has shown that repeated and unsustained diets often result in patients gaining weight that is sometimes greater than the previous weight loss. This is called the 'yo-yo effect'. This effect is partly due to the consequences of an unbalanced diet, which results in a decrease in energy requirements (basal metabolism) as a result of loss of lean body mass. These adjustments occur more quickly with successive diets, which means that energy is stored more easily than burned, making treatment increasingly difficult.

Treatment is only started for obesity with a BMI = 30 or for overweight with a BMI between 25-29.9 if comorbidity is present. In all other cases, the GP does not provide advice on a treatment approach, but can provide nutritional advice or refer patients for this at the patient's request.

This is a long-term process that takes place over several patient contacts. The therapeutic approach will also be different for each patient and will also be flexibly adjusted during long-term guidance.

A feasible goal is a weight loss of 5 to 10% of current body weight, over a period of six to twelve months. A moderate weight loss of 10% already leads to a significant reduction in health risks ( 43 ). After that, one tries to keep the weight stable.


Psychological effects of weight loss

For many obese people, the reasons for starting a diet are psychological in nature: they feel better (in their skin), their quality of life improves, and so on. In the clinic, we see that people are (rightly) satisfied and proud when they have lost weight ( 44 ). Moreover, the patient's environment will respond to this with a lot of praise. However, a diet can lead to psychological complaints in people without weight problems, but who only follow a diet for emotional reasons ( 45 ).

Weight loss results in a significant improvement in the overall quality of life ( 46 ). With the combination of a diet and behavioral therapy (lifestyle adjustments), we see, compared to a diet alone, a significantly greater improvement in the areas of mood (depression, anxiety) and psychological functioning.

There is a connection between weight loss and an improvement in body image, but this is not linear. In other words: greater weight loss is not correlated with a greater improvement in body image. On the other hand, a small weight gain can already mean a significant relapse.


Diet

Guidance during a diet includes the following points of attention:


starting from a healthy and varied diet based on the active food triangle;

starting from the patient's dietary pattern using a diary (self-monitoring) ( 47 );

guidance by a dietician.

Food Triangle

The starting point of an energy-restricted diet is a healthy, varied diet. The active food triangle (see figure 2) is a good tool to point out to the patient the right choices and proportions ( 48 ). Quantities are also indicated that can be indicative for comparison.




Figure 2: The active food triangle.




It can be assumed that an overweight patient has an unbalanced diet. This can be due to the omission of main meals (for example breakfast), which results in snacks being consumed throughout the day. Wrong choices are often made: lots of chips, sweets, biscuits, wrong preparation methods, fast food, alcoholic and soft drinks, etc.

The GP can give some useful advice:


A balanced energy-restricted diet includes three main meals (with three smaller meals in between, spread out over the day). Omitting a meal (such as breakfast) is a bad habit, because during the day one tends to satisfy one’s hunger with various snacks, which are usually energy-rich and result in a higher energy intake per day.

Limiting fat intake and simple sugars. The basis of each meal is formed by a fiber-rich source of complex carbohydrates (potatoes, wholemeal bread, whole rice or pasta).

Often it is enough to leave out snacks (candy, chips, nuts, cookies, soft drinks, alcoholic drinks). It can make a difference of about 200 kcal (2 glasses of lemonade or beer, 1 bag of chips of 30 g, 2 pralines) to 500 kcal (1 bag of fries of 150 g without mayonnaise) per day.

The best thirst quencher is water. Soft drinks contain a lot of carbohydrates that are quickly absorbed into the blood. Fruit juice contains the same percentage of energy as soft drinks. If necessary, regular soft drinks can be replaced by diet soft drinks. But even these remain accustomed to 'sweet'.

So-called diet margarine contains as much energy as butter, but has a better fatty acid composition. Minarine has only half the energy value of margarine.

Vegetables and fruit play an important role in a healthy diet. They have a low energy value and are rich in (soluble) dietary fibres, vitamins, minerals and bioactive substances.

A gastronomically tasty meal does not necessarily have to contain a lot of fat.

Self-monitoring

It is important to start from the patient's dietary pattern. The GP can have the patient write down everything he eats and drinks for one week. In such a diary, the patient carefully notes not only what and how much he eats, but also the place, time, frequency and circumstances of the food. He can take this diary with him to a subsequent visit to the GP or directly to the dietician. Based on this, the patient can be encouraged to change certain aspects of his dietary pattern: fewer snacks, more vegetables and fruit, etc. Working with a diary and self-monitoring does take a lot of time, which is usually not feasible in the average GP practice. Therefore, referral to a dietician is often necessary ( 49 ).


Guidance by a dietician

Nutritional history

A more or less thorough questioning of what the patient usually eats and when, gives an idea of ​​his eating habits and the circumstances (work situation, family situation, knowledge of nutrition, etc.) that influence the eating pattern. Such a thorough nutritional anamnesis takes about one hour. The questioning and calculation of the nutrients require a great deal of knowledge of food technology and preparation techniques, and a correct estimation of the quantities. Dieticians have been trained for this and it is therefore useful to refer to them.


Terms and Conditions

A prescribed 'diet' must meet a number of requirements:


balanced, healthy and varied,

individualized, that is to say adapted to the patient's living conditions,

simple and understandable,

feasible and acceptable,

safe, without risks,

with good results in the short and long term.

A balanced diet provides sufficient nutrients (proteins, fats, carbohydrates, vitamins, minerals, dietary fibres and fluids). Preventatively, attention is also paid to the right choice of fats.

The 'strictness' of the diet is determined by the severity of the obesity and the goal. With an energy-restricted diet (energy deficit of 500 kcal per day), a weight loss of half a kilo per week can be aimed for ( 50 ).

With a carefully kept diary, one can detect many errors and propose individually adapted corrections.

A predetermined daily schedule with examples of daily menus for a certain energy value, for example 1,600 kcal, does not take into account individual needs and can lead to errors ( 51 ).

In case of obesity (BMI >30) and for short-term treatment, one can opt for a 'Very Low Calorie Diet' (VLCD) with low-energy meal replacements (approx. 800 kcal/day), protein-rich food, supplemented with vitamins and minerals ( 52 ). The rapid weight loss motivates the patient. However, this method should always be combined with intensive guidance and follow-up (including monitoring of the fluid balance). These specific diets do not offer any long-term advantages compared to classic diet therapy.

With a strict hypocaloric diet ('Low Calorie Diet' or LCD of less than 1,200 kcal) based on regular foods, it is practically impossible to meet the recommended amount of all vitamins and minerals. Supplementation with a vitamin-mineral complex is therefore necessary.


Education

Nutritional education of the patient by the dietician includes providing insight into:


energy values ​​of foods, with attention to alcoholic beverages and soft drinks;

nutritional value of the foods (proteins, fats, carbohydrates, fibres, minerals such as calcium and iron, vitamins) and the different meals. Whole grain products, such as whole wheat bread and whole rice, legumes, are rich in complex carbohydrates and fibres. All vegetables and most fruits are low in energy, but rich in vitamins, minerals and trace elements;

choice of low-energy foods and light products;

low-fat cooking methods;

portion sizes: learning to use small portions;

correctly interpreting information on packaging;

adequate fluid intake.

Dietary prescription by the GP

A dietary prescription must contain the following information:


identification data;

weight, height, possibly BMI, weight evolution;

nature of the problem (type of obesity);

associated pathology (hypercholesterolemia, endocrinological problems);

prehistory;

activities/occupation (to calculate energy needs);

in case of specific pathology, for example hypercholesterolemia: add blood value, possible hypoglycemia, insulinemia, uremicemia;

medication: appetite suppressants, corticosteroids;

psychosocial problems;

expectations of the GP: concrete agreements regarding goals, such as losing X number of kilos;

any other dietary measures: sodium restriction, AVVZ diet (diet low in saturated fatty acids) in case of hyperlipidemia, restriction of alcohol;

reporting of: …

Behavioral advice

To gradually change the patient's eating behavior, the GP can give a number of specific advice (assignments) ( 53 ):


Overweight people are strongly influenced by external stimuli, such as the sight and smell of food. Examples of tasks that aim to limit the number of food stimuli are: eating at fixed times, eating in a fixed place and without performing other activities at the same time. It can help to put just enough on the table. After the meal, the leftover food is immediately put away. In fact, this stimulus control already starts when buying food. The patient can best go shopping on a full stomach and with a shopping list made in advance.

Furthermore, there is advice aimed at the eating behavior itself. The doctor can suggest to the patient to put down the cutlery between each bite, to eat bread with a knife and fork or even to eat with chopsticks instead of cutlery, and so on. In order to prevent emotional eating behavior, it can also help to look for a behavior that cannot be combined with eating (for example, talking on the phone, taking a shower).

The doctor builds in each advice step by step and re-evaluates it at a subsequent consultation. He praises and rewards positive changes and seeks out new behavioral advice. In these behavioral therapeutic measures, he does not focus on weight, but on eating behavior.

Often, weight loss reaches a plateau after a certain period of time. Then patients develop a thought pattern that increasingly discourages them and makes them drop out. The GP can counter this by recognizing, discussing, and questioning these typical thoughts (black-and-white reasoning, generalizations, or catastrophic thinking).


Exercise advice

Physical activity: an important pillar of treatment

The combination of dietary counseling, behavioral counseling, and exercise is more effective in losing and maintaining weight than either therapy alone. Weight loss is primarily caused by diet. Sustained increases in physical activity are especially important for maintaining weight loss ( 54 ).

Increasing physical activity also has a positive effect on ( 55 , 56 ):


body composition: 'fat-free' body mass increases (muscles) and fat mass decreases;

the fat distribution: abdominal fat decreases;

cardiorespiratory fitness (VO2 max) improves;

the risk of diabetes and cardiovascular diseases decreases;

the patient's general well-being increases.

In obese patients, physical activity increases should be gradual. The physician will assess for cardiovascular risk factors, pulmonary disease, metabolic disease, and/or osteoarticular or muscular disease ( 57 ). Potential side effects of increasing physical activity include muscle and/or joint injuries and cardiovascular events ( 58 ).

Exercise is not limited to sports. It is also important that the obese patient moves as much as possible in his daily life (taking the stairs instead of the elevator, walking or cycling to the store instead of driving) and limits 'sedentary activities' (watching TV) ( 59 ).

Walking for half an hour three times a week is a realistic starting point. After that, the intensity (faster walking, 'brisk walking') and frequency (almost every day of the week) can be increased ( 60 ). The long-term goal is for the patient to do moderate physical activity for 30 minutes almost every day of the week, such as walking, swimming, cycling (see table 4) ( 61 ).




Table 4: Energy expenditure including basal metabolic rate of a 100 kg person during home and sports activities ( 62 ).

Activity Energy consumption in kcal/hour

Inactive Resting (in the armchair) 105

Light Shopping (department store) 210

Washing dishes, ironing 240

Quiet walking (3 km/h) 260

Tidy up, dust, vacuum 260

Exercise bike (50 Watt) 315

Brisk walking (5 km/h) 420

Cycling quietly (16 km/h) 420

Gardening 450

Going up and down stairs 470

Painting, wallpapering 470

Moderate to dig 525

Exercise bike (100 Watt) 580

Cycling briskly (20 km/h) 630

Carrying shopping up the stairs 630

Swimming 630

Tennis 630

Intense Jogging (8 km/h) 840

Cross-country skiing 840


Exercise advice from your GP

Based on the available literature, we cannot conclude whether counselling by the GP to increase physical activity is useful. It may be, but this has not yet been proven ( 63 ).

Brief advice from the GP (3-5 minutes) during the consultation has a variable and usually limited effect. Physical activity can increase, but only for a short period (maximum three months) ( 64 ).

Training GPs in advising on increasing physical activity, in longer interventions that take into account the person's stage of behaviour change, in working with individual goals, in providing written advice or information, and in follow-up, could have longer-term effects ( 65 ).

In relation to counselling regarding the initiation and maintenance of physical activity, four principles are put forward in the literature ( 66 ):


Interventions to increase physical activity do not have to be time-consuming for the physician. Other healthcare providers in the practice can also include this.

The patient must be actively involved in that conversation (including setting goals).

Personal feedback and support (follow-up) are essential.

To remain sufficiently physically active, it is useful to participate in 'community' activities (joining local organisations, walking clubs).

Commercial programs

A recent Randomised Controlled Trial (RCT) evaluated a commercial programme in comparison with counselling and self-help ( 67 ). This showed that a well-designed commercial weight loss programme ('Weight Watchers') is more effective than a limited self-help programme. The 'Weight Watchers' programme included regular follow-up of participants and included the three pillars on which obesity management is based, namely a balanced diet, behavioural modification and increased physical activity. In the self-help group, participants received two 20-minute dietary consultations and, to support diet and exercise, leaflets and other material. The motivated participants in such a commercial programme achieved a weight loss of 5% on average and were able to maintain this after two years. However, this programme was not compared with active treatment and follow-up in general practice ( 68 ).


Medication

Medication is preferably used as little as possible. Prescribing medication is often just an extension of the doctor-patient contact, something that some patients need to be taken seriously or when things are difficult. However, there is a risk of somatic fixation.

The effectiveness of fiber-containing bulk preparations, plants or herbs and homeopathic remedies is not known or proven.

All of the products studied had only a limited effect on ultimate weight loss ( 69 ). In addition to the rebound effect after discontinuation, medications also have a number of side effects.

In the treatment of obesity, the following products are formally excluded because of their significant side effects: amphetamines and derivatives, laxatives, diuretics, hormones and thyroid derivatives, adrenal and pancreatic extracts ( 70 ). There are only two drugs whose long-term effectiveness has been scientifically studied and which are also relatively safe for the treatment of obesity, namely sibutramine and orlistat ( 71 ).

For these products, only weight loss and maintenance in the short and medium term were studied in patients with a BMI higher than 30 or comorbid patients with a BMI between 27 and 29.9. It has not been proven that they provide direct health benefits, in other words whether they result in a reduction in mortality or morbidity (diabetes, cardiovascular) ( 72 ).

Sibutramine has an anorexigenic effect ( 73 ) and is therefore indicated for patients with a great feeling of hunger. Side effects include increased blood pressure and increased heart rate. Sibutramine is started with a daily dose of 10 mg in one administration. After four weeks, in case of weight stagnation, the dose can be increased to 15 mg per day.

Orlistat inhibits fat absorption ( 74 ). It can be administered to patients with multiple cardiovascular risk factors ( 75 ). Orlistat mainly has gastrointestinal side effects. The recommended dose is 1 capsule of 120 mg shortly before, during or up to one hour after the three main meals.



Pharmacotherapy with orlistat or sibutramine can only be supportive in patients with a BMI greater than or equal to 30 kg/m2 or in comorbid patients with a BMI between 27 and 29.9 kg/m2. It is essential that this is always used as an adjunct in the multidisciplinary approach to obesity consisting of diet, physical activity and behavioural therapy ( 76 ). The expected additional effect on weight is limited, namely less than 5% and this with long-term therapy (six to 24 months). Long-term effects and also side effects are unknown. Additional drug treatment for obesity must therefore always be critically evaluated.



Surgery

Surgery can only be used when all other less invasive treatments have failed. Surgery is reserved for patients with morbid obesity (BMI >40 kg/m2) and for patients with a BMI higher than 35 kg/m2 and with comorbidity (cardiovascular disease, diabetes mellitus). A preoperative evaluation must always be performed before surgery to detect psychological and organic contraindications (sugar and/or alcohol dependency, psychiatric problems, severe depression, upper gastrointestinal or cardiovascular pathology).

The patient should be warned before surgery about the dietary changes resulting from and the risks of the procedure ( 77 ). These risks include the general risks of any abdominal procedure. In addition, late complications such as reflux esophagitis, vomiting, vitamin and mineral deficiencies, dumping syndrome, etc. may occur.

In consultation with a multidisciplinary team, the general practitioner selects patients who are eligible for bariatric surgery. The risks of the procedure are weighed against the known risks of persistent morbid obesity. The general practitioner chooses a center with sufficient experience in bariatric surgery.

Weight loss is maximal during the first six months and slows down thereafter. The average weight loss is 30 kg over twelve months. This weight loss is associated with a high degree of patient satisfaction, an improvement in quality of life and a significant correction of various risk factors ( 78 ).

There are two standard surgical procedures: those that reduce the size of the stomach and those that cause malabsorption ( 79 ).


Gastric reduction

Reducing the size of the stomach is the most appropriate procedure. This reduces the amount of food that is absorbed. The three most common gastric reduction techniques are vertical gastroplasty, placement of an adjustable gastric band, and Roux-en-Y gastric bypass. All techniques can be performed laparoscopically ( 80 ). The advantage of the adjustable gastric band is that the procedure is reversible: the gastric band can be removed. The Roux-en-Y gastric bypass results in faster and greater weight loss than gastroplasty, but is the most serious surgical procedure of the three ( 81 ).


Malabsorption

Malabsorption is achieved by means of diversion techniques (including intestinal bypass and the bile-opancreatic diversion or Scopinaro procedure). This procedure reduces the absorption of calories. However, these techniques are not recommended, because of the risk of serious complications.

After the procedure, multidisciplinary follow-up is essential for the success of weight loss and the detection of side effects of the procedure, in particular the quality and quantity of nutritional intake ( 82 ).


Planning

Appointments with the patient

The treatment of obesity is a step-by-step process. All phases of the treatment are shown in figure 3. Frequent contacts with the GP are necessary to achieve and maintain the desired weight loss. The GP clearly explains the phasing to the patient and indicates each time in which phase the patient is. At each consultation, the GP agrees on a feasible goal for the next visit. The consultations follow each other quickly at first, then the frequency decreases. However, we cannot provide concrete figures for the recommended frequency


Figure 3: Policy plan for tackling obesity in general practice. The various steps are gradually addressed in the course of the various consultations.

During the consultations, the focus should not be solely on weight and weight loss; the patient should always be positively stimulated. The GP should provide advice on lifestyle and diet during each consultation and motivate the patient to exercise. Preferably, a feasible frequency of weighing should be agreed with the patient ( 83 ). It is recommended that the patient's weight is checked regularly, even after the weight loss phase. This allows for timely intervention if the weight increases again. For many patients, the difference between success and relapse depends on some form of group support. There are various patient groups for people with obesity.


Reference

Good cooperation with a dietician/nutritionist is necessary. However, in certain cases a referral and a more specialized assessment are necessary, at least in morbid obesity in adults (BMI >40), obesity with associated pathology and binge eating disorders.


Preconditions

The GP must have skills to conduct a motivational interview and be able to integrate this expertly into one or more consultations. He must also be competent to give behavioural advice.

In order to be able to refer patients with binge eating disorders in a targeted manner, it is necessary for the GP to have a network of care providers and organisations that can deal with this problem expertly.

The GP should have more experience in working with dieticians.

Consultation with a dietician should be partially reimbursed, certainly for the first extensive consultation and the first follow-up consultation. This can significantly lower the threshold. This reimbursement should be linked to certain conditions: sufficient motivation, setting achievable goals such as achieving a weight loss of 5 to 10% in six to twelve months and the willingness to continue the follow-up for at least one year.

Research agenda

What is the long-term effect of weight loss on mortality?

What is the effect of a motivational interview on the successful initiation of obesity treatment?

What is the effectiveness of behavioral and exercise advice given to obesity patients by the general practitioner?

There are few possibilities in the treatment of obesity in terms of medicine. Further research is needed into new possibilities.

How can regaining effective weight loss be prevented (prevention of 'weight cycling')?

What are the elements of successful guidance and follow-up of obesity patients?

Creation

The authors of this recommendation are: Paul Van Royen (general practitioner, professor of general practice), Hilde Bastiaens (physician-researcher), An D'hondt (general practitioner), Chris Provoost (dietician) and Wout Van Der Borght (psychologist). Paul Van Royen wrote a draft text on obesity that served as a basis for the further development of the recommendation. The group of authors outlined the subject of the recommendation, as well as the clinical questions that had to be answered.

In order to collect relevant articles, the authors performed a systematic search on Medline (1994-2004). They used the following MeSH terms or a combination of them: “Obesity”, ”Obesity/Morbid”, “Body Mass Index”. For drug therapy they searched with the MeSH terms “Obesity/drug therapy” or “Anti-obesity agents”, for behavioral advice with the terms “Behavior Modification” and “Behavior Therapy” and for bariatric surgery with the MeSH terms “Bariatrics”, “Weight Loss” and “Surgical Procedures”. In addition, they consulted the Cochrane Library with the same search terms. Clinical Evidence and other guidelines were also consulted to compare with the information found by the author group. The retained articles were compared and tested for quality in a standardized manner. An assessment was made of the study relevance in terms of the clinical questions of the recommendation, of the study design and of the internal validity using score lists from the 'Dutch Cochrane Centre'.

Each author elaborated a part of the recommendation, based on the literature and on the formulated clinical question.

The draft text was sent for comment to the following experts: Dr. Folmer (general practitioner, Dutch College of General Practitioners, the Netherlands), Prof. Dr. J. Borms (Faculty of PE and Physiotherapy, Vrije Universiteit Brussel), Prof. M. Vervaet (Department of Psychiatry and Medical Psychology, Ghent University), Prof. C. Braet (Department of Developmental, Personality and Social Psychology, Ghent University), Dr. G. Thijs (physician, chair of the Consultation and Behaviour Change working group, Domus Medica), Dr. A. Franck (general practitioner in Wilrijk), Mrs. A. Van de Sompel (dietician, Antwerp University Hospital) and Dr. L. Van Krunkelsven (surgeon, Obesity Clinic, Jan Ypermans Regional Hospital, Ypres). Mention as an expert does not mean that every expert endorses the recommendation in every detail.

Their comments were discussed at the consensus meeting of 23 September and 28 October 2004, after which the text was amended on some points.

The authors and experts declared that they had no involvement with the pharmaceutical industry or other interest groups.

In five LOK groups (one in Cheratte, one in Brussels, two in Wilrijk and one in Roeselare) the draft recommendation was then tested for practical feasibility.

On 13 January 2005, the authors held a final consensus meeting. The reviews in the LOK groups were reviewed and discussed, after which a few changes were made to the draft text. The text was then presented to the editors of Huisarts Nu and finally submitted to CEBAM for validation.

The text will be updated annually. After five years, the recommendation will be fully updated. When following up on this recommendation, the main focus will be on checking whether the key messages are still applicable, based on a systematic literature search in the literature of the past year. The same search terms will be used for this as when this recommendation was developed. Only meta-analyses, systematic reviews and controlled research are eligible for this.

This recommendation was developed under the coordination of the Steering Committee Recommendations of Domus Medica vzw (Prof. Dr. Paul Van Royen, Dr. An De Sutter, Dr. Jan Michels, Dr. Samuel Coenen, Dr. Lieve Peremans, Dr. Hilde Philips, Dr. Frans Govaerts, Dr. Nathalie Van de Vyver and Cil Leytens) and with the support of the Flemish Community.