Family Practice Vol. 19, No. 5, 571
© Oxford University Press 2002
Book review |
Obesity and weight management in primary care.
Colin Waine. (128 pages, £14.95.) Blackwell Science Ltd, 2002. ISBN 0-632–06514-1.
Emeritus Professor of Human Nutrition in the University of London, and author of over 200 peer-reviewed papers on the causes, effects and treatment of human obesity
I approached this book with enthusiasm. The prevalence of obesity (BMI >30 kg/m2) among adults in the UK has trebled since 1980 and is still increasing. It now costs the NHS annually about £480 million to treat obese patients and another £165 million to treat that proportion of heart disease, stroke, diabetes, osteoarthritis and hypertension that can be ascribed to obesity. Since the problem is so important, both clinically and economically, it would be a real asset to have a concise, authoritative book to inform primary health care workers how to manage their overweight and obese patients.
Only 36 of the 118 pages actually deal with the management of patients: there are short chapters on "Beneficial effects of modest weight loss", "Management in clinical practice" and "The place of surgery in the management of obesity", each of six pages. The core of the book, physically and philosophically, is an 18-page chapter on "Drug treatment in the management of obesity" that deals in some detail with orlistat and sibutramine, the two drugs licensed in the UK for the treatment of obesity. These are described as being "imperfect but nonetheless valuable additions to the armamentarium of the clinician". I suppose that depends on the quality of the non-drug armamentarium of the said clinician. I am not impressed by the author’s grasp of the principles of energy balance. For example, I cannot agree with the calculation (on p. 64). The decrease of energy expenditure with age in men is said to be 350 kcal/day due to decreased physical activity, and 40 kcal/day between age 25 and 75 years due to decreasing BMR. "Taken together, these figures mean a decrease in energy expenditure of 700–800 kcal/day". On p. 52 "Nowadays it is generally agreed that a hypocaloric diet must create a 50–100 kcal/day energy deficit"; on that basis I am not surprised he finds dietary treatment ineffective.
Dr Waine mentions dietitians only once and that in a follow-up role once "the principles of dietary management" have been explained to the patient by the primary health care teams. Patients to receive lifestyle management must meet the criteria in a checklist (p. 49) that emphasizes that they should be "motivated". Ah yes! But of course some health carers are better than others at motivating patients. I think the author would benefit from closer liaison with dietitians.
So, for the unmotivated patient, are drugs the solution? The results of the best trials for 1 year show a loss of 10.3 versus 6.1 kg for orlistat/placebo, and 10.5 versus 8.3 kg for 15 mg sibutramine/placebo, with a large range about the mean. Some participants finish heavier than they started, but, because the trial numbers are large, the loss is statistically significant. I think Dr Waine is too enthusiastic about drug treatment and too dismissive of the alternatives.
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