Six Subgroups of Obesity Invite Targeted Management

Becky McCall

April 20, 2015

Six subgroups of obese individuals have been identified in a population-based study that looks into health, behavior, and demographic variables of individuals, with an aim to tailor management strategies depending on the subgroups that patients belong to.

The researchers found the greatest variation in conditions such as stroke, anxiety, and depression between the subgroups, suggesting that these were important in differentiating between types of obese individuals.

"One size does not quite fit all when it comes to obesity," remarked lead researcher Dr Mark Green, PhD, research associate in public health, University of Sheffield, United Kingdom.

"People with obesity can be very different, with important nuances, and we need to think about the complexities of managing the condition and how we can drive this forward into policy change."

He added that this was the first time that a range of six subgroups of people with obesity based on health and behavioral characteristics has been investigated.

Published online April 18 in the Journal of Public Health, the study identified the six groups of obese people as:

  • Younger healthy females.

  • Young males who were heavy drinkers.

  • Middle-aged individuals who were unhappy and anxious.

  • Older people who despite living with physical health conditions were happy.

  • Older affluent healthy adults.

  • Individuals with very poor health.

"With these six subgroups in mind, we need to stop treating everyone the same and start rethinking strategies for management and health promotion to take these groups into account and consider that some people might respond very differently [from others]," Dr Green told Medscape Medical News.

Tailoring treatment strategies could be both more effective clinically and provide a more efficient use of National Health Service (NHS) resources, he added.

Asked to comment, Dr Matthew Capehorn, clinical director of the United Kingdom's National Obesity Forum and a general practitioner in Rotherham, South Yorkshire, said the study "supports what clinicians and the National Obesity Forum have suspected and assumed for some time, which is that a 'one-size-fits-all' approach to weight management is just not as effective as a tailored, individualized approach."

However, Dr Capehorn pointed out that the subgroups identified are not as helpful as the concept of supporting individualized care. "I would find it hard to put my patients at the Rotherham Institute for Obesity into one of these six groups, or conversely, they may fit into several," he said, conceding that the authors of the paper do acknowledge that their results may not be generalizable to other obese populations.

Obesity Costs UK £6 Billion Annually; More Effective Strategies Needed

Dr Green explained that obesity currently costs the NHS close to £6 billion annually and that there are very few effective ways to approach the treatment over the long term. "The reason for this is that services are tackling everyone with obesity in the same way.

"It seems obvious, but to illustrate the point, if you tell a group with the poorest health to try to exercise more, then this just won't work," he said by way of illustration.

"Their priority is their health condition first, and weight loss might be more appropriate [in this context]. Exercise will come later. [But] with a group of young men, then exercise might be more appropriate."

Dr Capehorn too stressed the importance of knowing patients well, including the reasons they became obese in the first place and the barriers to why they are struggling to lose the weight.

"Then we tailor a program that is appropriate for them, which is best done in specialist weight-management centers."

"Exploratory" Cluster Analysis Used to Identify Six Groups

In their study, Dr Green and colleagues used data from the longitudinal observational Yorkshire Health Study (2010–2012), which collects information on the health and heath needs of individuals with a focus on weight management and chronic health conditions. Self-reported data from 4144 obese people with a body mass index (BMI) of 30 or above were included.

Demographic variables included in the analysis were age, sex, ethnicity, and socioeconomic deprivation. Health-related variables reported were fatigue, pain, insomnia, anxiety, depression, diabetes, breathing problems, high blood pressure, heart disease, osteoarthritis, stroke, and cancer.

Individuals' quality of life was also gauged, as was the level of general satisfaction with their lives. Behavioral characteristics assessed were smoking status, weekly alcohol intake, level of physical activity, and amount of walking each week. And participants were asked whether they engaged in active management of their own weight — for example, through exercise or the use of slimming clubs.

The researchers used a cluster analysis to derive the six groups, which looks for similarities across individuals based on certain characteristics. In particular, anxiety and depression, heart disease, high blood pressure, and alcohol intake were found to be important.

The largest cluster was younger healthy females (1021/4144 individuals), who displayed the most positive health characteristics of all the clusters and also engaged in some healthy behaviors.

Heavy drinking males (887/4144) were similar to younger healthy females except with respect to their high alcohol consumption, and they were also less likely to be managing their weight, although they did report above-average levels of physical exercise and walking, write the authors.

The next most common group was the physically sick but happy elderly (794/4144), who showed a higher prevalence of chronic health conditions, including osteoarthritis, diabetes, and high blood pressure, but low levels of anxiety and depression.

These were followed by the unhappy, anxious middle-aged (577/4144), who were primarily female with high values for insomnia, anxiety, depression, and fatigue. They engaged in healthy physical activity and in weight management and had the lowest alcohol consumption.

Next was the affluent, healthy elderly (555/4144), who have high blood pressure and above-average alcohol consumption, and finally, the group with the poorest health (310/4144), who had the most chronic conditions, lots of pain and fatigue, did not engage in healthy behaviors, and had the highest mean BMI.

Reflecting on the results, Dr Green stressed that the paper was exploratory but it did lead to some interesting observations.

The group of young men who drink excessively was interesting, for example. ""Managing the role of alcohol would appear important in maintaining a healthy body weight for some," he observed.

He also highlighted the unhappy and anxious middle-aged group for needing a different approach to managing their obesity that perhaps is not considered enough.

The authors refer to BMI as a "measure and classification tool for obesity," noting that their paper helps to drive debate around the application of BMI, "refining the measure to improve the detail it can offer as tool for grouping individuals."

Dr Green added that BMI is just a measure of height and weight, and "by itself, people who are obese are similar only in terms of these two factors. Therefore our six groups offer greater detail, rather than assuming that everyone is the same."

Future Work and Implications for Practice

With respect to future research, Dr Green would like to see these groups examined more closely and followed to see what happens as the people age. "Do they stay in one group throughout their lives or do they move between? Do people who are not obese enter one of these groups as their weight increases?"

Each group also needs to be examined in the context of exploring the cost of intervention to the NHS, including an examination of which policies would be most effective in which groups, he added.

Dr Capehorn provided some insight into how obesity is currently managed, stressing again that a more tailored approach is needed.

"Some overweight or obese individuals do well at community-based slimming groups and others don't.…Some do well on weight-loss pharmacotherapy or bariatric surgery, yet others don't. Government policy needs to take this into account.

"NHS England accepts that following initial primary activity there will be a second tier of community-based weight management, but for those who do not reach their weight-loss targets or for those with severe or complex obesity, then a third tier of intervention, adopting a specialist multidisciplinary team approach, is required to offer intensive and tailored medical intervention, especially prior to the consideration of bariatric surgery. Provision needs to made for this," he concluded.

Dr Green and coauthors have reported no relevant financial relationships. Dr Capehorn is clinical manager of the Rotherham Institute for Obesity (RIO), clinical director of the National Obesity Forum (NOF), and medical director for LighterLife; sits on advisory boards for Boehringer Ingelheim/Lilly Alliance, Novo Nordisk, and MSD; and has been a speaker in the past for these same companies and Janssen.

J Public Health (Oxf). Published online April18,2015.Abstract


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