Peter Kopelman

Management of obesity: Improvement of health-care training and systems for prevention and care

Although the caloric deficits achieved by increased awareness, policy, and environmental approaches have begun to achieve reductions in the prevalence of obesity in some countries, these approaches are insufficient to achieve weight loss in patients with severe obesity. Because the prevalence of obesity poses an enormous clinical burden, innovative treatment and care-delivery strategies are needed. Nonetheless, health professionals are poorly prepared to address obesity. In addition to biases and unfounded assumptions about patients with obesity, absence of training in behaviour-change strategies and scarce experience working within interprofessional teams impairs care of patients with obesity. Modalities available for the treatment of adult obesity include clinical counselling focused on diet, physical activity, and behaviour change, pharmacotherapy, and bariatric surgery. Few options, few published reports of treatment, and no large randomised trials are available for paediatric patients. Improved care for patients with obesity will need alignment of the intensity of therapy with the severity of disease and integration of therapy with environmental changes that reinforce clinical strategies. New treatment strategies, such as the use of technology and innovative means of health-care delivery that rely on health professionals other than physicians, represent promising options, particularly for patients with overweight and patients with mild to moderate obesity. The co-occurrence of undernutrition and obesity in low-income and middle-income countries poses unique challenges that might not be amenable to the same strategies as those that can be used in high-income countries.

Clinical obesity in adults and children.

The editors of this book are all professors, two of medicine and one of paediatrics, who have special interests in obesity. British and Australian medical schools are represented, alongside the Center for Disease Control. This comprehensive text is aimed at physicians, paediatricians and primary care practitioners who want to improve their knowledge about the insidious metabolic problems associated with obesity. The price is commensurate with the authorship. The book is divided in to six sections exploring obesity, biology, disease, management, childhood and environmental policy approach. Metabolic disorders including hypertension, diabetes and sleep apnoea are included. Medical, surgical and psycho-social methods of dealing with obesity and its consequences are evaluated. Ethnic differences are explored and adipose tissue is considered as a highly active, complex endocrine organ. The 60 contributors manage to unify the text into a readable, interesting volume. Each chapter is referenced using peer-reviewed journals and well-known studies including Framingham. The global authorship ensures that ethnic and cultural variations are considered. The Japanese are even more at risk from metabolic syndrome than South Asians. There is no section on the orthopaedic consequences of obesity but there is a chapter reviewing weight-loss surgical techniques. The tables in the new edition are current, showing the seemingly inexorable rise in obesity and associated metabolic disorders worldwide. Since the 2005 second edition the world economy has entered recession, climate change has become prominent, yet western societies cling to conspicuous consumerism. Obesity has become a major target for research in preventative medicine. All occupational physicians with clinical contact will find something of interest in the book. It may encourage more clinicians to weigh patients routinely as a health promotion tool. Obesity is not classified as a disease of occupation and I therefore recommend borrowing this rather than having your own copy.

Prevention of type 2 diabetes in British Bangladeshis: qualitative study of community, religious, and professional perspectives

Objective To understand lay beliefs and attitudes, religious teachings, and professional perceptions in relation to diabetes prevention in the Bangladeshi community. Design Qualitative study (focus groups and semistructured interviews). Setting Tower Hamlets, a socioeconomically deprived London borough, United Kingdom. Participants Bangladeshi people without diabetes (phase 1), religious leaders and Islamic scholars (phase 2), and health professionals (phase 3). Methods 17 focus groups were run using purposive sampling in three sequential phases. Thematic analysis was used iteratively to achieve progressive focusing and to develop theory. To explore tensions in preliminary data fictional vignettes were created, which were discussed by participants in subsequent phases. The PEN-3 multilevel theoretical framework was used to inform data analysis and synthesis. Results Most lay participants accepted the concept of diabetes prevention and were more knowledgeable than expected. Practical and structural barriers to a healthy lifestyle were commonly reported. There was a strong desire to comply with cultural norms, particularly those relating to modesty. Religious leaders provided considerable support from Islamic teachings for messages about diabetes prevention. Some clinicians incorrectly perceived Bangladeshis to be poorly informed and fatalistic, although they also expressed concerns about their own limited cultural understanding. Conclusion Contrary to the views of health professionals and earlier research, poor knowledge was not the main barrier to healthy lifestyle choices. The norms and expectations of Islam offer many opportunities for supporting diabetes prevention. Interventions designed for the white population, however, need adaptation before they will be meaningful to many Bangladeshis. Religion may have an important part to play in supporting health promotion in this community. The potential for collaborative working between health educators and religious leaders should be explored further and the low cultural understanding of health professionals addressed.

Weight Loss, HbA1c Reduction, and Tolerability of Cetilistat in a Randomized, Placebo-controlled Phase 2 Trial in Obese Diabetics: Comparison With Orlistat (Xenical)

The objective of this multicenter, randomized, double‐blind study was to determine the efficacy and safety of cetilistat and orlistat relative to placebo in obese patients with type 2 diabetes, on metformin. Following a 2‐week run‐in, patients were randomized to placebo, cetilistat (40, 80, or 120 mg three times daily), or orlistat 120 mg t.i.d., for 12 weeks. The primary endpoint was absolute change in body weight from baseline. Secondary endpoints included other measures of obesity and glycemic control. Similar reductions in body weight were observed in patients receiving cetilistat 80 or 120 mg t.i.d. or 120 mg t.i.d. orlistat; these reductions were significant vs. placebo (3.85 kg, P = 0.01; 4.32 kg, P = 0.0002; 3.78 kg, P = 0.008). In the 40 mg t.i.d. and placebo groups, reductions were 2.94 kg, P = 0.958 and 2.86 kg, respectively. Statistically significant reductions in glycosylated hemoglobin (HbA1c) were noted. Cetilistat was well tolerated, and showed fewer discontinuations due to adverse events (AEs) than in the placebo and orlistat groups. Discontinuation in the orlistat group was significantly worse than in the 120 mg cetilistat and placebo groups and was entirely due to gastrointestinal (GI) AEs. Treatment with cetilistat 80 or 120 mg t.i.d., or with orlistat 120 mg t.i.d., significantly reduced body weight and improved glycemic control relative to placebo in obese diabetic patients. Cetilistat was well tolerated with the number of discontinuations due to AEs being similar to placebo.

Substance misuse teaching in undergraduate medical education

BackgroundOver 12,000 hospital admissions in the UK result from substance misuse, therefore issues surrounding this need to be addressed early on in a doctor’s training to facilitate their interaction with this client group. Currently, undergraduate medical education includes teaching substance misuse issues, yet how this is formally integrated into the curriculum remains unclear.MethodsSemi-structured interviews with 17 key members of staff responsible for the whole or part of the undergraduate medical curriculum were conducted to identify the methods used to teach substance misuse. Using a previously devised toolkit, 19 curriculum co-ordinators then mapped the actual teaching sessions that addressed substance misuse learning objectives.ResultsSubstance misuse teaching was delivered primarily in psychiatry modules but learning objectives were also found in other areas such as primary care placements and problem-based learning. On average, 53 teaching sessions per medical school focused on bio-psycho-social models of addiction whereas only 23 sessions per medical school focused on professionalism, fitness to practice and students’ own health in relation to substance misuse. Many sessions addressed specific learning objectives relating to the clinical features of substance dependence whereas few focused on iatrogenic addiction.ConclusionsSubstance misuse teaching is now inter-disciplinary and the frequent focus on clinical, psychological and social effects of substance misuse emphasises the bio-psycho-social approach underlying clinical practice. Some areas however are not frequently taught in the formal curriculum and these need to be addressed in future changes to medical education.

Report of the substance misuse in the undergraduate medical curriculum project in England

Introduction: This article reports on a Department of Health UK funded project to implement consensus substance misuse teaching in undergraduate curricula in medical schools in England. The aim was to better equip practising doctors of the future to deal with substance misuse issues. Method: A project coordinator worked with local curriculum coordinators and academic champions in 19 participating medical schools. Substance misuse teaching was mapped using a toolkit outlining national learning outcomes as specified in Tomorrows Doctors. This enabled a detailed overview of current substance misuse teaching, and identified gaps. Results: Common areas for all schools requiring further development included iatrogenic addiction, professionalism, fitness to practice, attitudes and issues relating to stigma, child-related issues, and social consequences of substance misuse. Students reported lacking confidence in performing key skills, including substance use history taking, discussing options for patients wishing to reduce or stop use, and recommending appropriate help organisations. This led to medical schools developing new or enhanced learning outcomes and teaching materials. Discussion: The project has, through national guidance and changes, enhanced the training and education of student doctors, and established a basis for substance misuse teaching that has already influenced the learning of our future doctors.