A systematic review of interventions to improve health professionals' management of obesity

OBJECTIVE: To determine the existence and effectiveness of interventions to improve health professionals' management of obesity or the organisation of care for overweight and obese people. DESIGN: A systematic review of intervention studies, undertaken according to standard methods developed by the Cochrane Effective Practice and Organisation of Care (EPOC) Group. PARTICIPANTS: Trained health care professionals and overweight and obese patients. MEASUREMENTS: Objective measures of health professionals' practice and behaviours, and patient outcomes including satisfaction, behaviour, psychological factors, disease status, risk factors, and measures of body weight, fat, or BMI. RESULTS: Twelve studies that met all the review inclusion criteria were identified. Three were randomised controlled trials of health professional-oriented interventions (such as the use of reminders and training) and one was a controlled before and after study to improve collaboration between a hospital clinic and GPs. A further eight randomised controlled trials were identified of interventions comparing either the deliverer of weight loss interventions or the setting of the delivery of the intervention. The heterogeneity and generally limited quality of identified studies make it difficult to provide recommendations for improving health professionals' obesity management. CONCLUSIONS: At present, decisions about improving the provision of services for overweight and obese people must be based on the evidence from patient interventions and good clinical judgement. Future research is required to identify cost-effective strategies for improving health professionals' management and the organisation of care for overweight and obese people.     

Attentional biases for food cues in overweight and individuals with obesity: a systematic review of the literature

Obesity rates have increased dramatically in recent decades, and it has proven difficult to treat. An attentional bias towards food cues may be implicated in the aetiology of obesity and influence cravings and food consumption. This review systematically investigated whether attentional biases to food cues exist in overweight/obese compared with healthy weight individuals. Electronic database were searched for relevant papers from inception to October 2014. Only studies reporting food‐related attentional bias between either overweight (body mass index [BMI] 25.0–29.9 kg m^?2) or obese (BMI ≥ 30) participants and healthy weight participants (BMI 18.5–24.9) were included. The findings of 19 studies were reported in this review. Results of the literature are suggestive of differences in attentional bias, with all but four studies supporting the notion of enhanced reactivity to food stimuli in overweight individuals and individuals with obesity. This support for attentional bias was observed primarily in studies that employed psychophysiological techniques (i.e. electroencephalogram, eye‐tracking and functional magnetic resonance imaging). Despite the heterogeneous methodology within the featured studies, all measures of attentional bias demonstrated altered cue‐reactivity in individuals with obesity. Considering the theorized implications of attentional biases on obesity pathology, researchers are encouraged to replicate flagship studies to strengthen these inferences.     

Effects of nonnutritive sweeteners on body weight and BMI in diverse clinical contexts: Systematic review and meta‐analysis

There is an ongoing debate about the possible influences of nonnutritive sweeteners (NNS) on body weight. We conducted a systematic review and meta‐analysis of randomized controlled trials (RCTs) with NNS to assess their impact on body weight. We systematically searched for RCTs at least 4 weeks in duration, evaluating the effect of NNS on body weight, both in subjects with healthy weight and in subjects with overweight/obesity at any age, and compared the effects of NNS vs caloric and noncaloric comparators. The primary outcome was the difference in body weight between NNS and comparators. Twenty studies were eligible (n = 2914). Participants consuming NNS showed significant weight/BMI differences favouring NNS compared with nonusers. Grouping by nature of comparator revealed that NNS vs placebo/no intervention and NNS vs water produced no effect. When comparing NNS vs sucrose, significant weight/BMI differences appeared favouring NNS. Consumption of NNS led to significantly negative weight/BMI differences in unrestricted energy diets, but not in weight‐reduction diets. Participants with overweight/obesity and adults showed significant favourable weight/BMI differences with NNS. Data suggest that replacing sugar with NNS leads to weight reduction, particularly in participants with overweight/obesity under an unrestricted diet, information that could be utilized for evidence‐based public policy decisions.     

Commissioning guidance for weight assessment and management in adults and children with severe complex obesity

The challenge of managing the epidemic of patients with severe and complex obesity disease in secondary care is largely unmet. In England, the National Institute of Health and Care Excellence and the National Health Service England have published guidance on the provision of specialist (non‐surgical) weight management services. We have undertaken a systematic review of ‘what evidence exists for what should happen in/commissioning of: primary or secondary care weight assessment and management clinics in patients needing specialist care for severe and complex obesity?’ using an accredited methodology to produce a model for organization of multidisciplinary team clinics that could be developed in every healthcare system, as an update to a previous review. Additions to the previous guidance were multidisciplinary team pathways for children/adolescent patients and their transition to adult care, anaesthetic assessment and recommendations for ongoing shared care with general practitioners, as a chronic disease management pathway.     

Behavioural weight management for the primary careprovider

Primary care providers (PCPs) provide the majority of weight management care in clinical settings; however, they often lack the time or resources to apply strategies recommended in treatment guidelines. This review surveyed randomized clinical trials and prospective weight management studies from 1990 to present to identify evidence‐based behavioural strategies for weight management applicable to the PCP treatment environment. Data supported, time‐limited weight management strategies included self‐monitoring, portion control, sleep hygiene, restaurant eating and television viewing. The current review suggests that a number of behavioural strategies are available to enhance the effectiveness of PCPs weight management interventions. Increasing PCP awareness of these evidence‐based strategies may increase their attention to overweight and obesity concerns in clinical encounters and encourage more collaborative efforts with patients towards weight management goals.     

Obesity services: how best to develop a coherent way forward

Obesity now affects 25% of the UK population. This volume of patients cannot be managed by current NHS services. It really needs a public health approach which encourages an environment where it is easier for the public to take healthy rather than unhealthy actions. However, there remain substantial numbers of patients who will benefit from medical intervention. This needs a joined‐up service which extends from a healthy environment, linking gyms, weight loss groups, community cooking lessons, etc. with pathways connecting primary and secondary healthcare. To date, the National Health Service has not managed to develop a coherent policy that addresses obesity as a major cause of health and social care expenditure. The most important step in primary care is probably to identify the presence of obesity. The medical steps should be in the identification and management of comorbidities. The purpose of treating obesity is not weight loss alone but improving health, so the narrative needs to change from weight to blood pressure, glucose tolerance, physical fitness, etc. Many physicians believe that weight loss is an unwinnable battle but there are several well conducted studies in which primary care, supported by specialists, can deliver successful clinical weight loss. Specialist medical and surgical care for obesity will be required for complex cases and is essential for overseeing long‐term postsurgical follow‐up to prevent and treat nutritional and metabolic complications. Obesity management suffers from a lack of coherent national public health policies, fragmentation of care and a lack of knowledge of what successful treatment entails. Health benefits do not require a return to a healthy BMI.     

Implementation of pregnancy weight management and obesity guidelines: a meta‐synthesis of healthcare professionals' barriers and facilitators using the Theoretical Domains Framework

Obesity in pregnancy is rising and is associated with severe health consequences for both the mother and the child. There is an increasing international focus on guidelines to manage the clinical risks of maternal obesity, and for pregnancy weight management. However, passive dissemination of guidelines is not effective and more active strategies are required for effective guideline implementation into practice. Implementation of guidelines is a form of healthcare professional behaviour change, and therefore implementation strategies should be based on appropriate behaviour change theory. This systematic review aimed to identify the determinants of healthcare professionals' behaviours in relation to maternal obesity and weight management. Twenty‐five studies were included. Data synthesis of the existing international qualitative and quantitative evidence base used the Theoretical Domains Framework to identify the barriers and facilitators to healthcare professionals' maternal obesity and weight management practice. The domains most frequently identified included ‘knowledge’, ‘beliefs about consequences’ and ‘environmental context and resources’. Healthcare professionals' weight management practice had the most barriers compared with any other area of maternal obesity practice. The results of this review will be used to inform the development of an intervention to support healthcare professional behaviour change.     

Prevalence of overweight in the Seychelles: 15 year trends and association with socio‐economic status

We assessed the 15‐year trends in the distribution of body mass index (BMI) and the prevalence of overweight in the Seychelles (Indian Ocean, African Region) and the relationship with socio‐economic status (SES). Three population‐based examination surveys were conducted in 1989, 1994 and 2004. Occupation was categorized as ‘labourer’, ‘intermediate’ or ‘professional’. Education was also assessed in 1994 and 2004. Between 1989 and 2004, mean BMI increased markedly in all sex and age categories (overall: 0.16 kg m^?2 per calendar year, which corresponds to 0.46 kg per calendar year). The prevalence of overweight (including obesity, BMI ≥ 25 kg m^?2) increased from 29% to 52% in men and from 50% to 67% in women. The prevalence of obesity (BMI ≥ 30 kg m^?2) increased from 4% to 15% in men and from 23% to 34% in women. Overweight was associated inversely with occupation in women and directly in men in all surveys. In multivariate analysis, overweight was associated similarly (direction and magnitude) to occupation and education. In conclusion, the increasing prevalence of overweight and obesity over time in all age, sex and SES categories suggests large‐scale changes in societal obesogenic factors. The sex‐specific association of SES with overweight suggests that prevention measures should be tailored accordingly.     

Generalized Obesity but not that Characterized by Raised Waist‐Hip Ratio Is Associated with Increased Perceived Breathlessness During Treadmill Exercise Testing

The management of obesity is linked to defining its impact on exercise. One impact of obesity in coronary disease care is in the quantification of exercise limitation by treadmill protocols. In this study, we considered the impact of obesity as definition by body mass index (BMI) or waist‐hip ratio (WHR) on perceived exercise limiting symptoms, which are accepted and valuable targets for drug or lifestyle modification. We gathered morphometric data prospectively using bioimpedance (Bodystat^® Quadscan 3000), BMI, and WHR in 228 unselected cardiac patients attending for diagnostic Bruce treadmill tests. The patients were categorized as obese (BMI >30 kg/m²), overweight (BMI 25.0–29.9 kg/m²), or normal weight (BMI <25 kg/m²). A quantitative visual analog scale (10 cm) of perceived breathlessness was defined by the subjects at the end of each stage along with standard exercise data. In total, 188 patients were included for the final analysis excluding 12 patients with severe LV dysfunction and 10 patients with severe inducible ischemia necessitating an early termination of the test. There was no difference by obesity indices in the distribution of reasons for stopping the test (elective arrhythmia, inducible ischemia, or intolerable functional symptoms). Perceived symptom score on the visual analog scale were persistently higher at the end of stages 1, 2, and 3 of the Bruce protocol in obese individuals as compared with overweight and normal weight subjects. (P= 0.034, 0.003, and 0.042, respectively). Perceived symptoms during exercise when assessed by WHR did not show any statistical difference in severity. Generalized obesity associated with a high BMI is associated with increased perceived breathlessness during standard exercise testing regardless of ischemia or known left ventricular systolic function. This clearly indicates that perceived breathlessness does not correlate with obesity as defined by WHR, which is known to be a more sensitive marker of coronary disease. Therapeutic interventions in obesity should take into account the frame of reference of definition of obesity.     

The relationship between doctors' and nurses' own weight status and their weight management practices: a systematic review

It has been established that health professionals' smoking and physical activity influence their related health‐promoting behaviours, but it is unclear whether health professionals' weight status also influences their related professional practices. A systematic review was conducted to understand the relationship between personal weight status and weight management practices. Nine eligible studies were identified from a search of the Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL and Chinese databases. All included studies were cross‐sectional surveys employing self‐reported questionnaires. Weight management practice variables studied were classified under six practice indicators, developed from weight management guidelines. Syntheses of the findings from the selected studies suggest that: normal weight doctors and nurses were more likely than those who were overweight to use strategies to prevent obesity in‐patients, and, also, provide overweight or obese patients with general advice to achieve weight loss. Doctors' and nurses' own weight status was not found to be significantly related to their referral and assessment of overweight or obese patients, and associations with their relevant knowledge/skills and specific treatment behaviours were inconsistent. Additionally, in female, primary care providers, relevant knowledge and training, self‐efficacy and a clear professional identity emerged as positive predictors of weight management practices. This review's findings will need to be confirmed by prospective theoretically driven studies, which employ objective measures of weight status and weight management practices and involve multivariate analyses to identify the relative contribution of weight status to weight management.     

High Blood Pressure in Overweight and Obese Youth: Implications for Screening

In the absence of evidence‐based guidelines for high blood pressure screening in asymptomatic youth, a reasonable strategy is to screen those who are at high risk. The present study aimed to identify optimal body mass index (BMI) thresholds as a marker for high‐risk youth to predict hypertension prevalence. In a cross‐sectional study, youth aged 6 to 17 years (n=237,248) enrolled in an integrated prepaid health plan in 2007 to 2009 were classified according to their BMI and hypertension status. In moderately and extremely obese youth, the prevalence of hypertension was 3.8% and 9.2%, respectively, compared with 0.9% in normal weight youth. The adjusted prevalence ratios (95% confidence intervals) of hypertension for normal weight, overweight, moderate obesity, and extreme obesity were 1.00 (Reference), 2.27 (2.08–2.47), 4.43 (4.10–4.79), and 10.76 (9.99–11.59), respectively. The prevalence of hypertension was best predicted by a BMI‐for‐age ≥94th percentile. These results suggest that all obese youth should be screened for hypertension.     

Effects of weight loss in overweight/obese individuals and long-term lipid outcomes – a systematic review

This paper aims to review the evidence for long‐term effectiveness of weight loss on cholesterol, high‐density lipoprotein (HDL), low‐density lipoprotein (LDL) and triglycerides in overweight/obese people. Current evidence is mostly based on short‐term studies. A systematic review of long‐term lipid outcomes of weight loss in studies published between 1966 and 2001, was conducted. Inclusion criteria included all cohort studies and trials carried out on participants with body mass index of greater than or equal to 28 kg m^?2. Studies had at least two weight change measurements and follow‐up of more than 2 years. Thirteen long‐term studies with a follow‐up of more than 2 years were included. Cholesterol has a significant positive linear relationship with weight change (r = 0.89) where change in weight explains about 80% of the cholesterol difference variation (Adj R² = 0.80). For every 10 kg weight loss a drop of 0.23 mmol L^?1 in cholesterol may be expected for a person suffering from obesity or are grossly overweight. Weight loss has long‐term beneficial effects especially on LDL and cholesterol. Weight loss in obese patients should be encouraged and sustained.     

Prevalence and impact of obesity in people with haemophilia: Review of literature and expert discussion around implementing weight management guidelines

Obesity affects more than 35% of Americans, increasing the risk of more than 200 comorbid conditions, impaired quality of life and premature mortality. This review aimed to summarize literature published over the past 15 years regarding the prevalence and impact of obesity in people with haemophilia (PWH) and to discuss implementing general guidelines for weight management in the context of the haemophilia comprehensive care team. Although few studies have assessed the effects of obesity on haemophilia‐specific outcomes, existing evidence indicates an important impact of weight status on lower extremity joint range of motion and functional disability, with potentially important effects on overall quality of life. Data regarding bleeding tendency in PWH with coexisting obesity are largely inconclusive; however, some individuals may experience reduced joint bleeds following moderate weight loss. Additionally, conventional weight‐based dosing of factor replacement therapy leads to increased treatment costs for PWH with obesity or overweight, suggesting pharmacoeconomic benefits of weight loss. Evidence‐based recommendations for weight loss include behavioural strategies to reduce caloric intake and increase physical activity, pharmacotherapy and surgical therapy in appropriate patients. Unique considerations in PWH include bleed‐related risks with physical activity; thus, healthcare professionals should advise patients on types and intensities of, and approaches to, physical activity, how to adjust treatment to accommodate exercise and how to manage potential activity‐related bleeding. Increasing awareness of these issues may improve identification of PWH with coexisting obesity and referral to appropriate specialists, with potentially wide‐ranging benefits in overall health and well‐being.     

Epidemiology of obesity

Overweight and obesity are conditions characterized by weight levels higher than the normal limits for age, sex, and height. Because people stratified for sex and age vary in stature and this influences weight, criteria for being overweight must take height into account: this is defined and set out in WHO guidelines on the basis of Body Mass Index (BMI): weight (kg)/height2 (m2). Obese and overweight individuals are at a greater risk of developing chronic metabolic conditions and general ill health, than those whose weights are within the recommended guidelines. Besides these chronic related conditions for which obesity is a major risk factor incur enormous expenditure. The health hazards of obesity are compounded by the influence of central fat distribution. The disease associations of central fat are present even in people who are not overweight. Waist circumference is a simple measure that gives a very reasonable estimate of the amount of central fat. Data collected in the USA and Europe show a common trend: the increase of obesity and overweight among the adult and children population. Obesity appears to be the result of several factors that interact among them such as: genetic, environment, and behaviour. Current strategies, such as reducing food intake, seem to lead to poor long term outcomes. Management has tended to neglect the unavoidable need to consider obese subjects as chronically ill patients, requiring continuous assistance for active steps to maintain weight loss. Treatments should be multidisciplinary aiming at the achievement of radical changes in the individual's lifestyle. The planning and management of preventive programs for young people such as pubertal children have been disregarded up to now. They require not only attention, but also organization, clear goals and standardized methods. Moreover, a correct education is a key-element of these issues. Our unit has designed for this purpose an observational study aimed to reach a better comprehension of the proportion of 'weight problems' and eating behavioural patterns in a population of adolescents.     

Body mass index,obesity, and prevalent gout in the United States in 1988–1994 and 2007–2010

Objective

To determine the association and prevalence of gout among overweight, obese, and morbidly obese segments of the US population.

Methods

Among participants (age ≥20 years) of the National Health and Nutrition Examination Surveys in 1988–1994 and 2007–2010, gout status was ascertained by self‐report of a physician diagnosis. Body mass index (BMI) was examined in categories of <18.5 kg/m², 18.5–24.9 kg/m², 25–29.9 kg/m², 30–34.9 kg/m², and ≥35 kg/m² and as a continuous variable. The cross‐sectional association of BMI category with gout status was adjusted for demographic and obesity‐related medical disorders.

Results

In the US, the crude prevalence of gout was 1–2% among participants with a normal BMI (18.5–24.9 kg/m²), 3% among overweight participants, 4–5% with class I obesity, and 5–7% with class II or class III obesity. The adjusted prevalence ratio comparing the highest to a normal BMI category was 2.46 (95% confidence interval [95% CI] 1.44–4.21) in 1988–1994 and 2.21 (95% CI 1.50–3.26) in 2007–2010. Notably, there was a progressively greater prevalence ratio of gout associated with successively higher categories of BMI. In both survey periods, for an average American adult standing 1.76 meters (5 feet 9 inches), a 1‐unit higher BMI, corresponding to 3.1 kg (～6.8 pounds) greater weight, was associated with a 5% greater prevalence of gout, even after adjusting for serum uric acid (P < 0.001).

Conclusion

Health care providers should be aware of the elevated burden of gout among both overweight and obese adults, applicable to both women and men, and observed among non‐Hispanic whites, non‐Hispanic African Americans, and Mexican Americans in the US.     

Harnessing glucagon‐like peptide‐1 receptor agonists for the pharmacological treatment of overweight and obesity

Over the past 30 years, there has been a dramatic rise in global obesity prevalence, resulting in significant economic and social consequences. Attempts to develop pharmacological agents to treat obesity have met with many obstacles including the lack of long‐term effectiveness and the potential for adverse effects. Historically, there have been limited treatment options for overweight and obesity; however, since 2012, a number of new drugs have become available. A number of peptides produced in the gut act as key mediators of the gut–brain axis, which is involved in appetite regulation. This review discusses the role of the gut–brain axis in appetite regulation with special focus on glucagon‐like peptide‐1. Liraglutide 3.0 mg, a glucagon‐like peptide‐1 receptor agonist that targets this pathway, is now approved for the treatment of obesity and overweight (body mass index ≥27 kg/m²) with comorbidities such as type 2 diabetes, high blood pressure, high cholesterol or obstructive sleep apnoea. In addition, other glucagon‐like peptide‐1 receptor agonists offer promise for obesity management in the future. This review examines how glucagon‐like peptide‐1 receptor agonists promote weight loss and summarizes the clinical data on weight loss with glucagon‐like peptide‐1 receptor agonists.     

Applicability of the European Society of Cardiology guidelines on management of acute coronary syndromes to people with haemophilia – an assessment by the ADVANCE Working Group

There are no evidence‐based guidelines for antithrombotic management in people with haemophilia (PWH) presenting with acute coronary syndrome (ACS). The aim of the study was to review the current European Society of Cardiology guidelines, and to consider how best they should be adapted for PWH. Structured communication techniques based on a Delphi‐like methodology were used to achieve expert consensus on key aspects of clinical management. The main final statements are as follows: (i) ACS and myocardial revascularization should be managed promptly by a multidisciplinary team that includes a haemophilia expert, (ii) each comprehensive care centre for adult PWH should have a formal clinical referral pathway with a cardiology centre with an emergency unit and 24 h availability of percutaneous coronary intervention (PCI), (iii) PCI should be performed as soon as possible under adequate clotting factor protection, (iv) bare metal stents are preferred to drug‐eluting stents, (v) anticoagulants should only be used in PWH after replacement therapy, (vi) minimum trough levels should not fall below 5–15% in PWH on dual antiplatelet therapy, (vii) the duration of dual antiplatelet therapy after ACS and PCI should be limited to a minimum, (viii) the use of GPIIb‐IIIa inhibitors is not recommended in PWH other than in exceptional circumstances, (ix) the use of fibrinolysis may be justified in PWH when primary PCI (within 90 min) is not available ideally under adequate clotting factor management. It is hoped that the results of this initiative will help to guide optimal management of ACS in PWH.     

An inventory of healthy weight practices in federally funded haemophilia treatment centres in the United States

In the haemophilia population, obesity has an adverse effect on health care cost, chronic complications and joint disease. Although staff of federally funded Hemophilia Treatment Centers in the United States (HTCs) anecdotally recognize these outcomes, practices to promote healthy weights have not been reported. This evaluation identifies routine practices among HTCs in body mass index (BMI) assessment, perceptions about need to address obesity and roles in offering evidence‐based strategies to promote healthy weights. A telephone survey was developed to assess HTCs practices including patient BMI assessment and counselling, perceptions about the importance of healthy patient weights, and HTCs roles in weight management. Ninety of the 130 federally funded HTCs contacted elected to participate and completed the telephone survey. Of these, 67% routinely calculated BMI and 48% provided results to patients. Approximately one‐third classified obesity correctly for children (30%) and adults (32%), using the Centers for Disease Control and Preventions BMI cut‐offs. Most HTCs (87%) reported obesity as an issue of ‘big’ or ‘moderate’ concern and 98% indicated HTC responsibility to address this issue. Most centres (64%) address patient weight during comprehensive visits. One‐third (33%) of centres include a nutritionist; of those without, 61% offer nutrition referrals when needed. Most (89%) HTCs do not have a protocol in place to address healthy weights; 53% indicated that guidelines are needed. HTCs offer services to help improve weight outcomes. Training programmes for calculating and interpreting BMI as well as identifying appropriate guidelines to apply to the HTC patient population are needed.     

A systematic review and meta‐analysis of the effectiveness of meal replacements for weight loss

Meal replacements (MR) are generally not recommended in clinical guidelines for the management of obesity. The aim of this review is to provide an up‐to‐date systematic evaluation of the effect of weight loss interventions incorporating MR compared with alternative interventions on weight change at 1 year in adults with overweight or obesity. Six electronic databases were searched from inception to the end of August 2018 for randomized controlled trials comparing the effect of MR with interventions that did not include MR on weight at 1 year. We excluded studies using diets providing <3347 kJ/(800 kcal)/day and those which used total diet replacement (TDR) from this review. Risk of bias was assessed using the Cochrane risk of bias tool. Twenty‐three studies with 7884 adult participants were included. Six out of 23 studies were judged at low risk of bias across all domains, and 5/23 studies were judged at high risk of bias in at least one domain. Studies with similar intervention and comparators were grouped into five comparisons for analysis. Mean weight change at 1 year favoured the MR group relative to the control group in each comparison. In those comparisons where we conducted meta‐analysis, in people assigned to a diet incorporating MR, mean difference was ?1.44 kg (?2.48 to ?0.39 kg; I² = 38%) compared with alternative kinds of diets. In those assigned to a MR diet along with support, mean difference was ?2.22 kg (?3.99 to ?0.45, I² = 81%) compared with other diets with support and ?3.87 kg (?7.34 to ?0.40; I² = 60%) compared with other kinds of diet without support. In those assigned a MR diet with an enhanced level of support, mean difference was ?6.13 kg (?7.35 to ?4.91, I² = 19%) compared with alternative diets and regular support. Programmes incorporating meal replacements led to greater weight loss at 1 year than comparator weight loss programmes and should be considered as a valid option for management of overweight and obesity in community and health care settings.