“Would it be ok to talk about your weight?”
Weight loss is key to prevention and management of type 2 diabetes. Speaking at the 17th National Conference of the Primary Care Diabetes Society (PCDS) recently, Jennifer Logue, Professor of Metabolic Medicine, Lancaster University, shared some tips on how best to work with your patients on this crucial issue. Dr Susan Aldridge reports.
The UK has a clear, four-tiered system of weight-management services within the NHS, ranging from Tier 1, which is general healthy living activities provided by local authorities through to Tier 4, meaning bariatric surgery and other specialist treatments for people living with obesity, who have been unable to lose weight in any other way. All of that notwithstanding, Professor Logue told delegates at the PCDS conference in December: “Provision and access to weight-management services is a bit of a mess and I can’t fix it in this presentation. I know some of you will be looking at these four tiers and thinking ‘not in my area. Provision is patchy, with not all tiers available in all areas.”
So how do you work with whatever weight-management services are available when it comes to type 2 diabetes? Who do you send to which tier?
“You have people at risk of type 2 diabetes and people who have been diagnosed with it. These are two different conditions and we must treat them differently,” said Professor Logue. For those at risk, primary prevention is the focus, with weight loss, prevention of weight gain and physical activity being the main components. “Here weight reduction is paramount and we should aim for 5 to 10% weight loss, and there are various approaches to this, including the NHS Diabetes Prevention Programme.”
For those who already have type 2 diabetes, regardless of whether they are newly diagnosed or have longer established diabetes, you would aim for 15% weight loss with diet or even surgery. Whether the goal is remission or risk management would usually depend on how far along the type 2 diabetes journey the person is. Newly diagnosed patients are more likely to be able to achieve remission through weight loss. “For those with established diabetes, the aim is usually risk reduction, rather than remission – maybe you can reduce progression to the need for insulin in these individuals.”
Three simple steps
These are the easy things you can do to help your people with, or at risk of, type 2 diabetes. First, reduce the stigma attached to obesity. “We know that they have shorter consultation times and their uptake of prevention and screening is less. This is because of the experiences of healthcare that people with obesity have had in the past, either through the setting or the way people have treated them.” In other words, it looks as if obesity stigma reduces people’s contact with the healthcare services. “So, look at your language. Don’t say ‘diabetic’ or ‘obese’ but rather ‘living with diabetes’ and ‘living with obesity’.”
The second simple step is to be sure to use the correct classification of obesity, based upon the person’s body mass index (BMI). The current system could be improved, of course, but let’s work with what we have now.
And the final step is to actually measure and record BMI, and note any changes. “It’s a simple thing to say, but in practice it doesn’t actually happen,” said Professor Logue, citing a study from 20 years ago that showed that even in cardiology, where weight is particularly important, weight was measured in only 67% of cases and height in only 4% – so BMI data was scarce. Numbers were even lower in orthopaedics and rheumatology. “Things haven’t changed for the better in 20 years and this has not been helped by the shift from paper to electronic records,” she said. “The last two years have made things worse, because you can’t measure BMI in a phone appointment. So, you must always measure and record BMI whenever you get the chance and note any changes.”
Having done these three things, what next? “First, establish priorities. Consider the overall physical and emotional state of the person in front of you, or on the phone. If weight is a top priority, discuss it with the patient. If other things are higher priority, make a note and come back to the weight issue.”
Ask, assess, assist
It is important not to tell the patient they have obesity – they already know that. “Also, try to avoid saying ‘problem’ or ‘concern’ – instead, ask: ‘Would it be OK if we talk about your weight?’” said Professor Logue. “I moved to using this line in my own practice five years ago. The response you get when you ask that question, when you ask for permission, is very different from if you raise in any other way. Also, try to put a positive spin on the discussion and talk about how losing weight could help your condition.”
Then it is time to assess. How important is losing weight to your patient? How confident do they feel that they can do it?
Finally, if the patient is ready, assist them by referring to the local tiered service as appropriate, and make sure they know what to expect from it. If they are not ready to lose weight, make sure they at least know about services that are available locally and how weight loss can help them. Maybe they will discuss it with their friends and family and you can also raise the issue at their next appointment. “Finally, make sure to encourage and congratulate them on their weight loss efforts,” said Professor Logue.
The obesity multidisciplinary team
The dietitian, physiotherapist, specialist nurse, occupational therapist and the endocrinologist are the regular members of the obesity multidisciplinary team (MDT). However, Professor Logue would like to see this broadened out. “Obesity is at the centre of a cluster of multiple long-term conditions, including gout, depression, dyslipidaemia , type 2 diabetes, hypertension, non-alcoholic fatty liver disease, sleep apnoea, arthritis and gastrointestinal reflux. All of these are related to obesity.” This means bringing in respiratory, liver, gastrointestinal and psychiatric specialists and so on, where possible.
And Professor Logue would make the obesity MDT even wider than this, to address the socioeconomic issues underlying obesity and include teachers, food banks, employment advisors and debt advisors, using the social prescribing approach. “We need to adopt a holistic, patient-centred approach to obesity,” she said. Clearly the NHS’s tiered weight management services, where available, would play an important role, but these are likely to be more successful if complemented by other inputs against a background of increased awareness of the complexity of obesity within primary care.
Any opinions expressed in this article are the responsibility of the EASD e-Learning Programme Director, Dr Eleanor D Kennedy.