Referral to a physiotherapist or exercise physiologist is the next step, to both prescribe appropriate exercise for the patient and address barriers to activity. Severe osteoarthritis should not preclude exercise. Finally, identification of psychological issues that lead to comfort eating or underlying eating disorders should prompt referral to a clinical psychologist as this intervention takes priority.
Alternatively, Virginia may be referred to a multidisciplinary obesity service, which is available at several major tertiary hospitals. These services may have available all or several of the following staff: dietitian, exercise physiologist, specialist nurse, psychologist and supervising endocrinologist specialising in obesity medicine. A rheumatologist review may be warranted in those patients who may benefit from symptomatic relief with intra-articular corticosteroid injection if simple analgesics are inadequate.
After a period of 12 months, the care team should review the patient. The following should be assessed:
- has the weight loss plateaued despite good application of treatment?
- would the patient benefit from continued weight loss?
- would the patient be compliant with the postoperative requirements of metabolic surgery (previously known as bariatric surgery), such as very low calorie diets, follow-up appointments, exercise?
- are psychological factors related to excess energy intake (e.g. comfort eating, eating disorders) absent or treated?
If the answers to all of the above questions are yes, then a referral to a sugeon specialised in metabolic surgery is warranted, ideally one who participates in the national bariatric surgery registry. The timing and type of surgery are tailored to the patient’s individual goals, and weighed against the risk of postoperative complications.
Excess energy intake, which is often driven by multiple factors, is invariably responsible for longstanding insidious weight gain. A detailed dietary history taken from the patient (or a household cohabitant) in a nonjudgemental fashion using the SPEL dietary questionnaire will, with time, provide the answer. Investigations are not complex and include cardiometabolic and nutritional screens, an assessment for fitness for exercise and possibly, in more complicated patient cases, referral of patients to a multidisciplinary obesity service.
Many patients will, with treatment, be able to lose between 5 and 15% of their initial weight. Metabolic surgery should be considered in patients with persistent obesity-related comorbidities that will likely benefit from further weight loss, as long as their increased energy intake is not primarily caused by a psychological disorder. If the latter is the case, treatment by a clinical psychologist or psychiatrist is the main priority. MT