Issue: 2015, Vol 1, No 1, Pages 1–40

Annual Conference of the National Obesity Forum 2014: From broad horizons to individual focus

The Annual Conference of the National Obesity Forum 2014 took place on 26 November 2014 and was titled From broad horizons to individual focus: Offering personalised care through quality local services supported by national guidance. Key topics included bariatric surgery, psychological aspects, obesity in pregnancy and children, and diet and exercise.

David Haslam, Chair of the conference and of the National Obesity Forum, welcomed the delegates and provided a round-up of the Forum's activities in 2014, which included publishing the State of the Nation's Waistline report and the results of the Healthier Choices Pilot, in which, simply by rearranging the layout and shelving of a supermarket, they were able to increase the sales of fruit and vegetables by 30% and oily fish by 10%.

Overcoming obesity: an initial economic analysis

Corinne Sawers, Fellow, McKinsey Global Institute

In a last-minute addition to the programme, the opening session began with a discussion of obesity from a global economic perspective, following publication of a new report by the McKinsey Global Institute. The cost of obesity to the global economy has now increased to US$2 trillion (£1.2 trillion), behind only smoking and armed violence in the order of anthropogenic social costs.

McKinsey's analysis identified 75 obesity interventions across multiple domains. While no single intervention will be a silver bullet, combined application of multiple initiatives could reduce the prevalence of obesity in the UK by 20% within 5 years, and nearly all of the individual interventions are cost-effective. An outline for a pilot scheme to implement these measures across the whole of Government, healthcare, education and the food industry was also discussed.

Delivering high-quality local care in obesity

Carly Anna Hughes, Clinical Lead, Fakenham Weight Management Service

Dr Hughes described a number of initiatives that have been set up in Norfolk to improve local care in weight management, including the comprehensive, Tier 3, primary care-based Fakenham Weight Management Service. Key to her message was the fact that the multidisciplinary team was the key component of the programme, and she described the make-up and skill set of a gold-standard team.

Managing the morbidly obese child

Julian Hamilton-Shield, Professor in Diabetes and Metabolic Endocrinology, University of Bristol

The management of the ever-increasing number of morbidly obese children, who in the UK now number between 8000 and 10 000 in the most conservative estimations, was discussed in the third presentation. Julian Hamilton-Shield described the morbidities associated with severe childhood obesity, commenting that children who develop type 2 diabetes secondary to obesity are likely to have worse outcomes than those with type 1 diabetes.

Methods to manage obesity in this patient population, including devices that slow eating speed, pharmacological agents, immersion treatment (e.g. weight loss camps) and, in highly selected patients who have received full psychological clearance, bariatric surgery, were also discussed.

Best practice in pregnancy

Sangeeta Agnihotri, Consultant in Maternal Medicine, Obstetrics and Gynaecology, London

Sangeeta Agnihotri described the known complications of obesity in pregnancy, as well as the evidence-based recommendations for management before conception, during pregnancy and postpartum. Many misconceptions about a healthy lifestyle in pregnancy, such as the concept of eating for two and omitting physical activity for fear of harming the fetus, persist today.

The importance of pre-pregnancy BMI and weight gain during pregnancy were also discussed. Above all, the need to convey the risks and provide advice sensitively is paramount, as it is impossible to do so without causing fear, anxiety and guilt in the mother, making her less likely to comply with advice.

Obesity in the mind

Jen Nash, Clinical Psychologist, Chartered with the British Psychological Society

Jen Nash sought to provide a psychology-based paradigm for understanding why people consistently fail to lose weight. In addition to biological necessity, we eat food for emotional and social reasons. Identifying such triggers and replacing eating as a coping strategy can be very helpful in reducing food intake.

The EatingBlueprint (available at: www.PsychBody.com) was also described. This online, video-based resource is in development and features bite-sized 10–30-minute sessions that patients can use alone or with their practitioner.

Novel insights and approaches in obesity management

Neil Munro, Visiting Professor, University of Surrey and Associate Specialist in Diabetes, London

Dr Munro described a number of new therapeutic avenues for weight loss that are being explored. Beyond orlistat, several drugs that might be available in the future were discussed, along with agents that convert white fat into the more metabolically healthy brown fat and treatments that alter the gut microbiota. Mechanical devices currently in development include an implantable electrical stimulator that modifies hormone secretion and alters glucose and fat metabolism. An endoscopic duodenal-jejunal bypass sleeve is also being researched, which may have similar weight-loss effects to a gastric band.

Which diet, which patient?

Adrian Brown, Specialist Weight Management Dietitian, Imperial College London

In this presentation, Adrian Brown discussed the latest evidence and guidelines on formula diets and other approaches. Meta-analyses show that clinicians can recommend any diet that a patient will adhere to, whether it be low-fat or low-carbohydrate, as there is minimal difference between the individual named diets. Very-low-calorie diets (VLCDs), however, are not recommended without medical supervision in either the NOF or the 2014 NICE obesity guidelines. In selected, motivated patients, they have been shown to be highly effective in the short term, but there are considerable safety concerns. Studies comparing VLCDs with low-calorie diets show little difference in weight-loss outcomes, particularly over the long term. The use of VLCDs for rapid weight loss (e.g. before bariatric surgery) was also evaluated. These diets are effective in terms of reducing liver size and improving the ease of the operation, but there is conflicting evidence about their optimal duration, typically 2–6 weeks.

Obesity under the skin: Should we reconsider our dietary fat recommendations?

Julie Lovegrove, Professor of Human Nutrition, University of Reading

The intake of total dietary fat in the UK population is meeting the current recommendation of <35% of daily energy intake. However, intakes of saturated fats (derived from processed foods and animal products) are in excess of the recommended 10% of total energy. Historically, low-fat, high-carbohydrate diets have been recommended, yet this may not be the most appropriate nutritional strategy for reducing cardiometabolic risk. Julie Lovegrove discussed current guidelines and the evidence in relation to their potential efficacy. Replacing saturated fats with unsaturated fats, such as monounsaturated or polyunsaturated fats, may confer greater risk reduction than replacement with carbohydrates, particularly refined carbohydrates.

Professor Lovegrove went on to present the emerging evidence that the consumption of milk and some dairy products are associated with a reduced risk of CVD outcomes, despite their high levels of saturated fat. Removing milk from the diet, therefore, may not be the best solution for improving cardiovascular risk.

Going under the knife

Francesco Rubino, Chair of Bariatric Surgery, King's College London

Francesco Rubino went through the range of bariatric surgery options available. Long-term studies with up to 20 years' follow-up show dramatic and sustained weight loss following surgery, whereas conventional techniques are unlikely to result in long-lasting weight loss. In addition, surgery reduces the risk of developing type 2 diabetes by up to 80%, and can even reverse the condition, often for many years or decades.

Discussing the risks associated with bariatric surgery, Professor Rubino noted that it has a similar risk profile to other forms of invasive surgery; however, contrary to its general perception, gastric bypass is associated with a lower risk of re-operation than gastric banding. His conclusion was that surgery is not risk-free and should be used sparingly; however, he pointed out the role of surgery in the treatment of type 2 diabetes, a novel concept that goes under the name of metabolic surgery. Although this is now supported by substantial clinical evidence, as recognised by recent NICE guidelines, surgery remains severely underutilised in the UK compared with other industrialised countries.

A balanced approach to exercise

John Blundell, Professor and Chair in PsychoBiology, University of Leeds

In the final presentation of the day, the adage that body weight can be explained simply by calories in versus calories out was dismissed as being too simplistic. Professor Blundell explained the interactions between physical activity, body composition, appetite and energy intake, showing that exercise not only increases energy expenditure but also improves appetite control. In normal-weight people, increased fat mass actually inhibits appetite; however, this effect diminishes with increasing adiposity, such that obese people do not experience appetite suppression. Furthermore, their increased fat-free mass and resting metabolic rate increase the drive to eat. This is one of the reasons why it is so difficult for obese people to lose weight.