HOT TOPICS OBESITY

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HOT TOPICSOBESITY

• Andrew Forrester
• Sept 2006

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Scale of the problem

• Approx 1 in 5 adults in UK obese
• 1980 just over 7 of adults
• 2002 over 22
• Future estimate (2020), 33
• For children (2-15) proportion of obese increased
  from 11 to 19 from 1995 to 2004

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Defining Obesity

• Adults
• Use of BMI most widely recognised
• BMI gt25 Overweight
• BMI gt30 Obese
• BMI gt40 Morbid obesity
• (BMI gt25 obese for Asian or Pacific Island
  population (NICE guidance))
• Note fat distribution is assoc. with CVD risk
  independently of body weight
• Children
• Age and gender specific centile charts
• gt91st centile overweight
• gt98th centile obese

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What are the problems with obesity?

• Financial burden
• In 1998 estimated cost 0.5 billion for treatment
  and 2.1billion in lost productivity
• Health cost
• Hypertension
• Type II Diabetes
• Ischaemic Heart Disease
• CVA
• Some cancers (eg breast or colon)
• obesity can deprive an individual of an extra 9
  years of life

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Health cost

• Obese woman
• 3.2 x risk of MI
• 12.7 x risk of NIDDM
• Obese man
• 1.5 x risk of MI
• 5.2 x risk of NIDDM

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Benefits of weight loss

• moderate weight loss of 510 of body weight will
  have a major impact
• 510 kg loss has been shown to improve back and
  joint pains, symptoms of breathlessness and sleep
  apnoea

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Benefits of 10 weight loss

• Mortallity
• gt20 decrease in total mortallity
• gt30 decrease in diabetes related deaths
• gt40 decrease in obesity related cancers
• Blood pressure
• fall of 10 mmHg systolic
• fall of 20 mmHg diastolic
• Diabetes
• 30 - 50 fall in fasting glucose
• 50 fall in risk of diabetes developing
• 15 decrease in HbA1c
• Lipids
• 10 decrease in total cholesterol
• 15 decrease in LDL cholesterol
• 30 decrease in triglycerides
• 8 increase in HDL cholesterol

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Role of primary care

• GPs set for greater role after national
  Counterweight Project found intensive lifestyle
  intervention produced sustained reduction in
  weight, BP and Chol over 2 years.
• QOF points to be added

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Who should we treat?

• Patients with BMI gt30
• Patients with BMI gt27 with co-morbidities, e.g.
  COPD, coronary heart disease and diabetes.
• Patients who self-refer, where appropriate.
• Parents of families with more than one obese or
  overweight member may need special consideration
  and more intensive support.

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Patients readiness to lose weight

• Are you concerned about your weight?
• Do you believe that you could lose weight?
• How important to you is it to lose weight at the
  moment?
• What would have to change in your life for you to
  be able to tackle your weight?

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Weight management programmes

• Aims
• Lose and maintain weight loss and manage
  interacting risk factors
• Offered by PCT, local dietetic department,
  commercial slimming group, pharmacy, or self-help
  group
• Practice should hold details of all
  weight-management groups (commercial, NHS, and
  community-based) in the locality

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Weight loss programmes

• Should last about 3 months
• Aim for 5-10 kg weight loss (0.5 kg/week) or
  5-10 reduction from initial body weight
• Diet, increased physical activity, and behaviour
  change are the three main components that
  constitute the effective management of obesity
• Drug treatment may be needed in some people
• Surgery is an option for a small proportion of
  morbidly obese people who are unable to lose
  weight in other ways

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Diets and life-style changes

• Low fat diets are the most successful long term
• 500kcal/day deficits produce greater compliance
• Exercise is the best predictor for successful
  weight loss
• (Atkins diet does not improve weight loss after
  one year and concerns re. renal function, BMD,
  CVD and cancer.)

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• Regular review is necessary
• Subsequently a weight-maintenance period of 3
  months is advised
• Most people gain some weight in the months or
  years after their weight-loss period. To maintain
  weight loss, permanent lifestyle changes are
  needed
• Referral to a specialist centre should be
  considered if a person's BMI remains gt35

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Drug Treatment

• Only consider if BMI gt30 or if BMI gt27 in those
  with other risk factors ie. Type 2 diabetes,
  hypertension or hypercholesterolaemia
• And for Sibutramine the person has had difficulty
  achieving or maintaining at least 5 weight loss
  through lifestyle change within the last
  3 months
• (Nice Guidelines)

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Orlistat (Zenical) 39.50 for 4 weeks

• Intestinal Lipase inhibitor
• Blocks the absorption of about 30 of dietary fat
• Clinical trials showed 10 loss in 2 years
• Continue beyond 6 months only if 10 weight loss
• Some weight loss due to decreased fat intake
• Vitamin supplements may be considered

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Sibutramine (Reductil) 45 for 4 weeks

• Inhibits re-uptake of noradrenaline and serotonin
• Appetite suppressant
• May stimulate energy expenditure
• Not licensed for over 1 year
• Continue beyond 3 months only if 5 weight loss

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Rimonabant (Acomplia)

• Acomplia is a selective CB1 endocannabinoid
  receptor antagonist
• believed to play a role in controlling food
  consumption
• Not licensed by SMC

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All 3 drugs have effects over and above weight
loss

• Orlistat
• Reduces LDL cholesterol, TGs and insulin
  resistance
• Sibutramine
• Increases HDL cholesterol
• Rimonabant
• Increases HDL cholesterol and improves insulin
  resistance

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Weight reduction surgery

• Recommended by NICE in morbid obesity (BMI gt40 or
  BMI gt35 with co-morbidities) providing
• Aged 18 (no upper limit)
• They have been receiving intensive management in
  a specialized hospital obesity clinic
• There is evidence that all appropriate and
  available nonsurgical measures have been
  adequately tried
• They are generally fit for anaesthesia and surgery

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In the media

• Jamies school dinners
• Call for fertility ban for obese August 06
• British Fertility Society recommends women with
  a BMI gt35 should not be allowed access to
  fertility treatment

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In the media

• Generation XXL July 06 The number of
  teenagers who are overweight is heading towards
  50

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In Summary

• More responsibility for GPs
• Huge potential benefits
• Be aware of lower thresholds for different ethnic
  groups
• Make use of anti obesity drugs
• Importance of life style changes and exercise

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Any Questions?
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Useful Links

• www.nationalobesityforum.org.uk
• Guidelines for Adult and Childhood obesity
• www.nice.org.uk
• Guidelines on Orlistat, Sibutramine
• Obesity (to be published Nov 2006)
• www.sign.ac.uk
• Guidelines on Childhood obesity