GPwSIs in diabetes: Waist management operatives?

According to the World Health Organization (WHO), obesity is now a bigger problem worldwide than smoking (WHO, 2003). Over two-thirds of adults in England have a body mass index (BMI) over 25 kg/m² (National Centre for Social Research, 2004) and obesity is the prime determinant of the metabolic syndrome, according to the International Diabetes Federation (2005).

So how can we enthusiasts in the community – GPs, nurses and dietitians – hope to stem this tide? The accompanying article by Jonathan Pinkney gives us a thoughtful and realistic positioning of obesity in the 21st century health service, as well as some thought-provoking ideas and, more importantly, some strategies to work with in primary care. 

New QOF indicator for obesity
The new General Medical Service’s Quality and Outcomes Framework (QOF) is getting nine new areas for 2006/2007, including obesity (http://www.bma.org.uk/ap.nsf/Content/revisionnGMSFeb20062 [accessed 10.03.2006]). There is one indicator for obesity, worth 8 points: ‘The practice can produce a register of patients aged 16 and over with a BMI greater than or equal to 30 in the previous 15 months.’ BMI-calculating machines, as seen in your local Tesco, may help.

Although the points allocated for obesity may seem paltry, it’s at least a recognition by the Government that obesity is not just a cardiovascular risk factor. After all, in primary care we also see the effects of obesity on people with joint and mobility problems, sleep apnoea, some cancers and depression. There are many other consequences.

Public Health White Paper
Much was made of obesity, particularly childhood obesity, in the long-awaited White Paper Choosing Health: Making healthy choices easier (Department of Health, 2004), which was in part a response to the report Tackling Obesity in England (Audit Commission, 2001). This report, although commenting on the variation in obesity services in the NHS as a whole, noted that almost all of the services provided were in primary care. The White Paper itself noted that ‘within a generation obesity will cause a 20% increase in heart disease and a 50% increase in type 2 diabetes.’ 

So how far have we come since the White Paper was published? On the bad side, it looks like the UK will miss its first target on childhood obesity (Cole, 2006). However, the well-respected National Obesity Forum, founded in May 2000 by some enthusiastic doctors, has produced a weight management protocol as well as a very useful obesity care pathway and toolkit (http://www.nationalobesityforum.org.uk/apps/content/html/ViewContent.aspx?id=6548 [accessed 10.03.2006]).

A review of the Counterweight Programme (Laws et al, 2004b) in 40 general practices, however, noted poorly organised care despite appreciation of the problem by GPs and practice nurses. The intervention arm of this programme (Laws et al, 2004a) does give us hope that structured care results in better outcomes – have you heard that before somewhere?

A changing world
In the wider world as well, the impact of obesity seems to be hitting home. Recently, for instance, shares in Britvic, the maker of Pepsi and Tango in the UK, dropped by over 20% with fears of changing consumer preferences (http://news.bbc.co.uk/1/hi/business/4766518.stm [accessed 10.03.2006]).

Markers change as well: the INTERHEART study (Yusuf et al, 2004) shows that abdominal obesity may be a better marker than BMI for coronary heart disease. So, in the same way that we started taking socks off to assess foot problems, let’s get our tape measures out and start tackling this literally enormous problem, as Jonathan Pinkney suggests.