Opinion  

Dr David Haslam is a GP in Hertfordshire and clinical director of the National Obesity Forum. He took charge of formulating the guidelines for obesity management in primary care and has also been invited to sit on a four-man working party by the Royal College of Paediatrics and Child Health to develop the first guidelines for management of childhood obesity. David has articles widely published in journals and papers and has spoken internationally on obesity.

There is so much evidence linking obesity to serious chronic diseases that it must be treated as a medical condition in its own right. Risk of coronary heart disease is quadrupled by obesity, hypertension is five times more likely, and risk of type-2 diabetes is almost 100-fold at BMI 35 compared to a person of 'normal' weight.

Even clinicians who don't believe obesity is a medical condition must admit that it is a physical sign of likely underlying pathology. Waist circumference is a particularly valuable sign, as it is directly proportional to the amount of the dangerous, metabolically active visceral fat, which confers risk on abdominally obese patients.

Identify patients with weight-related problems

However, just as there are smokers who don't get lung cancer or COPD, there are obese people who escape without progressing to type-2 diabetes or CVD, and live to a ripe old age. The characteristics of the obese patients who present to us vary enormously.

There are those who want to lose weight before their summer holiday, those with symptoms unrelated to their obesity, those unaware that their problem is linked to their weight and those who already suffer from established disease. There are those patients who are motivated to lose weight, and those who are not.

The trick is to identify those people whose weight is already causing health problems, or is likely to in the future, in order to practise primary prevention or treat established disease.

The GMS contract and its quality and outcomes framework has affected the way we manage diabetes and CVD in our clinics. However, obesity was almost completely ignored in the contract's first incarnation, with three points available for measuring BMI in patients with diabetes and none for childhood obesity.

The latest revision of the contract, which becomes active in April, has improved the total to eight points, but this is still far too few, considering almost a quarter of the population is obese.

The fact that obesity is present in the contract shows that its importance in the disease process is recognised, so to include its recording but nothing else is illogical.

What the contract has done, however, is given obesity a disease category of its own. This recognises that it is too late to start measuring waist and BMI once diabetes or established CVD has been diagnosed. The reason for measuring waist and BMI is to identify high-risk individuals before disease develops.

However, the register of obese patients we are being asked to develop will include cosmetic slimmers and unmotivated people, as well as those with metabolic syndrome who are destined to die early of chronic disease. It does nothing to help us identify which is which.

This means, unless we are motivated to go above and beyond the letter of the contract, we do absolutely nothing. The way to identify at-risk individuals is to record and register obesity, and then assess obese individuals for other markers of cardiometabolic disease: blood pressure, lipid profile, and glycaemic control. Only then can we target our precious resources on those found to be at highest risk.

Changes to QOF must be built on in future

The eight points are a step toward primary prevention. We must ensure that this is built upon in future revisions of the contract, with the expectation that weight management programmes and eventually outcomes will be rewarded, and childhood obesity specifically included.

But management of the obese patient is only part of the story. The root causes of obesity are many, but as clinicians we have a role to play in matters such as promotion of breastfeeding and antenatal nutrition and healthy lifestyle advice as part of new patient and routine checks.

But even if prevention of obesity is 100 per cent successful with immediate effect, there are a sufficient number of obese individuals in the UK to make epidemics of diabetes and CVD inevitable, unless treatment is also prioritised. A good first step would be to include obesity recording and assessment, and the offer of weight management programmes in the next revision of the GMS contract.