The incidence of obesity worldwide continues to increase alarmingly. Obesity has a major impact on the health of the individual and if left untreated can lead to several diseases, including the metabolic syndrome, hypertension, diabetes, osteoarthritis, and BPH  and prostate cancer . Moreover, it might also have a psychological impact, leading to low self-esteem and reduced quality of life. As the urologist is very often the first specialist a middle-aged man might encounter as a patient, he or she is in a unique position not only to assess the extent of central obesity and evaluate associated comorbidities, but also to inspire the individual to set in motion corrective measures designed to achieve a realistic target for reduction of 5–10% of the patient’s original weight.
Obesity is already a major problem in the UK, and one which already affects ≈29% of men. The incidence of diabetes in the USA is approaching 10% in some states, and the situation is deteriorating in many other countries . However, the battle against obesity is not hopeless. Motivation and behavioural change provide the foundation to successful weight reduction, and importantly, its maintenance over time. Urologists, as advocates of ‘Men’s Health’, can provide the motivation and inspiration for a radical change of lifestyle in their patients. Very often, significant effort and resources are wasted on diet-based weight-loss solutions that do not support long-term behavioural modification. A successful intervention for weight management must adopt a holistic approach and be developed by ongoing negotiation between the person and his clinician.
The body mass index (BMI) should be used as a measure of obesity, but needs to be interpreted with caution, because it is not a direct measure of obesity. Waist circumference, measured at the level of the umbilicus, not where the belt is worn, is a useful and easy supplement to BMI. Significantly, this value is one that is often severely underestimated by patients. Raising the issue of obesity for the first time during a consultation might provoke surprise, anger, denial or disbelief. The National Institute for Clinical Excellence guideline suggests that several areas should be explored, in particular the person’s view of their weight gain, possible reasons for it, eating patterns and exercise levels, together with beliefs and attitudes to these subjects . Following these discussions the psychosocial or psychological distress associated with lifestyle, environment and family factors should be assessed, including a family history of obesity. An integral part of the evaluation is a review of comorbidities, which might include type 2 diabetes, hypertension, dyslipidaemia and sleep apnoea.
Achieving behavioural change requires an agreement about realistic goals and actions. Skilful and sensitive communication is required, avoiding jargon and most importantly using praise and encouragement to underline successes, however small. A series of strategies, tailored to the individual, should be deployed, which might include self-monitoring of behaviour and progress, stimulus control, goal setting and a slower rate of eating. In men particularly, reducing the amount of alcohol consumed in the evenings can be critical. The health benefits of exercise should be underlined. Men should be encouraged to do at least 30 min, or preferably longer, moderate-intensity physical activity on five or more days per week. To actively lose weight and maintain the benefit patients should be advised that 60–90 min of moderate-intensity exercise per day might be necessary, ideally in two separate sessions each day. The rationale for twice-daily exercise stems from the observed increase in basal metabolic rate that lasts for up to 15 h after each session, and this obviously enhances its weight-reduction potential. The possibility of acquiring exercise equipment, such as a rowing machine or cross trainer, to use at home should be discussed.
Men should be encouraged to improve the overall healthiness of their diet. The main requirement of a dietary approach to weight loss is, self-evidently, that total energy intake should be less than energy expenditure. A diet that has a 600-kcal/day deficit, especially one that reduces fat intake, is often recommended. Low-calorie diets (1000–1600 kcal/day) might be considered, but are less likely to be nutritionally complete; very-low-calorie diets (<1000 kcal/day) should not be used for >12 weeks continuously. If this sort of dietary approach is successful, it is critical that the nutritional modifications are included into ongoing lifestyle change, to discourage the regain of weight.
Several approved and evidenced-based pharmacological interventions are now available for treating obesity. Orlistat is licensed for use as part of an overall plan for managing obesity in adults with a BMI of 30 kg/m2, or 28 kg/m2 plus associated risk factors, such as diabetes. Orlistat reduces the absorption of dietary fat by inhibiting gastrointestinal lipase. Two systematic reviews that evaluated patients who had taken orlistat for a year, as well as eating a low-calorie diet and/or exercising, have shown a mean weight reduction of 8.1 kg . This weight reduction was 2.8 kg more than in those who had taken placebo [5,6]. The most frequent adverse effects with orlistat are gastrointestinal, resulting from the blockage of intestinal fat breakdown and absorption, and include oily leakage from the bowels, liquid stools, flatulence and abdominal discomfort.
Sibutramine acts centrally by enhancing satiety and attenuating the adaptive decline in resting metabolic rate during weight loss. It works most effectively when combined with a counselling strategy that achieves behavioural change. Like orlistat, it should only be continued for >3 months in patients who have achieved at a ≥5% reduction in their body weight since starting drug treatment. Blood pressure and pulse should be monitored during treatment. The most frequent side-effects include dry mouth, constipation and insomnia [7–9].
Surgical intervention should only be considered in patients in whom all appropriate nonsurgical measures have been tried and failed, and who have a BMI of ≥40 kg/m2 or 35 kg/m2 and other significant disease, such as diabetes, that could be improved if they lost weight. Bariatric surgery might also recommended as a first-line option instead of lifestyle interventions or drug therapy in those with a BMI of >50 kg/m2. The procedures used include adjustable silicone gastric banding and gastric bypass, and are best done by specialist units with an extensive experience with the techniques.
In conclusion, obesity is becoming an epidemic problem which is destined to afflict increasingly many of our patients. Rather than be ignored, the issue should be addressed pro-actively as part of the original prostatic or erectile dysfunction (ED) problem that brings the patient into the sphere of the urologist. If any urological surgical intervention is contemplated, a weight-reduction programme can have a significant benefit on the outcome. If ED is the presenting symptom, weight reduction can significantly reduce associated cardiovascular risk and might even improve the ED. During the follow-up positive messages about the benefits of maintaining the lifestyle modifications that resulted in the original loss of weight can be reinforced. This more holistic approach befits modern urology and the urologist, and seems to be the way ahead as we continue to expand our role to encompass the broader speciality that constitutes Men’s Health .