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Rotherham Institute for Obesity (RIO) Multidisciplinary approach to the management and prevention of obesity - a working model Dale Carter Obesity Specialist.

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Presentation on theme: "Rotherham Institute for Obesity (RIO) Multidisciplinary approach to the management and prevention of obesity - a working model Dale Carter Obesity Specialist."— Presentation transcript:

1 Rotherham Institute for Obesity (RIO) Multidisciplinary approach to the management and prevention of obesity - a working model Dale Carter Obesity Specialist Nurse (OSN) Rotherham Institute for Obesity

2 To discuss: 1) Why do we care about obesity? 2) Waist circumference and central/visceral fat 3) Weighing and measuring 4) The NHSR obesity strategy and RIO 5) Common myths and mistakes 6) Questions?

3 The cover of "The Economist", Dec , 2003.

4 How things have changed: The changing look of women The changing look of men

5 It’s getting worse Kids today! How we could end up by 2050

6 Impact of obese population

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8 Obesity – Public health concerns 2011 Health Survey for England (2009 data): 22% of men and 24% of women are obese (BMI >30) Increasing numbers are morbidly obese (BMI >40) and ‘super obese’ (BMI >50) 66% men and 57% women obese or overweight Foresight report (Oct07): estimates on current trends >50% of the UK will be obese by 2050  Currently 2/3 adults and 1/3 children overweight or obese  Without action 9/10 and 2/3 by 2050 By 2050 total direct and indirect costs of obesity may increase to £49.9bn

9 Obesity – it’s a social problem, isn’t it?  Yes...but, we treat social problems all the time eg, sporting injuries, smoking problems, common infections etc  Plus...we treat the consequences of obesity anyway, eg, dyslipidaemia, T2DM, hypertension So why not treat the cause?  Cost effective – prescribing savings  Even a few kilos makes a difference to individuals  Any weight loss reduces morbidity and mortality  Weight regain is inevitable (whatever intervention) Obesity is a chronic relapsing condition

10 Weight Change Start3 Months6 Months12 Months24 Months kg All (completers) n = 684, 12m High Attenders n = Low Attenders n = 262 Haitman BL & GarbyL (1999) Int J Obes Relat Metab Disord Expected change

11 Pulmonary disease obstructive sleep apnea Asthma/COPD Nonalcoholic fatty liver disease steatohepatitiscirrhosis Coronary heart disease Dyslipidemia Hypertension HypertensionDiabetes Gynaecologic abnormalities abnormal menses infertility polycystic ovarian syndrome Osteoarthritis Gall bladder disease Cancer breast, uterus, cervix colon, esophagus, pancreas kidney, prostate Phlebitis venous stasis Leg ulcers pressure sores Hyperuricaemia and Gout Stroke Diseases related to obesity Stress incontinence

12 Relative risk of health problems associated with obesity National Audit Office Report. Tackling Obesity in England. London, DiseaseWomenMen T2D Hypertension Myocardial infarction Colon cancer Angina Gall bladder disease Ovarian Cancer Osteoarthritis Stroke

13 Onyike, et al. Amer J Epidemiology 2003;158: Risk of Major Depression with Extreme Obesity Odds ratio BMI

14 Weight Loss Reduces Mortality Betteridge DJ and Morrell JM Clinicians' Guide to Lipids and Coronary Heart Disease Second edition Arnold, London 2003 p173 (based on Jung R. Obesity as a disease. Br Med Bull 1997; 53 (2): Weight loss of 10 kg produces a marked improvement in mortality Mortality  > 20-25% fall in mortality  > 30-40% fall in diabetes-related deaths  > 40-50% fall in obesity-related cancer deaths Blood pressure  Fall of approximately 10 mmHg SBP and DBP Diabetes  Fall of 50% in fasting glucose Lipids  Fall of 10% in total cholesterol  Fall of 15% in LDL-C  Fall of 30% in triglycerides  Rise of 8% in HDL-C

15 BMI classification of obesity BMI = weight(kg)/height(m)2 WHO Classification BMI Risk of Comorbidity Underweight Below 18.5 Low (but risk of other clinical problems increased) Healthy weight Average Overweight Mild increase Obese>30.0 Grade 1 obesity Moderate increase Grade 2 obesity Severe increase Grade 3 obesity (morbid obesity) >40.0 Very severe Source: Adapted from WHO, 1995, WHO, 2000 and WHO 2004

16 Android (apple) vs. gynoid (pear) obesity A tribute to a pioneer: Jean Vague (1947) RIM06/413

17 Visceral Fat ©1994 Mayo Foundation for Medical Education and Research. By permission of Mayo Foundation.

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20 Women >88 cm (80cm) = Increased risk Men >102 cm (94cm) = Increased risk Lean MEJ et al. Lancet; 1998; 351:853-6 Body fat distribution Apple shaped obesity cm

21 Excess visceral fat: a root cause of CVD and Type 2 diabetes Treating the causeTreating the complications

22 So, what works? NICE Recommends (for adults):  Diet  Exercise  Behavioural therapy  Drug treatment  Surgery (if BMI >40, or >35 with co-morbidities) NICE Clinical Guideline 43; Treating people who are overweight or obese. Dec 1996

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24 Explaining calories P /June 2007

25 The role of Exercise  Isolated exercise is an inefficient way of burning calories and losing weight  1 mile (15 mins) burns up 100kcals  Regular exercise has a huge effect on burning calories and losing weight  Energy expenditure = BMR x PAL (modified Harris Benedict equation)  BMR (kcal/day): Age (yrs) Men Women x Kg x Kg + 746eg, x Kg x Kg yr old man 80kg x Kg x Kg + 829BMR = 1903 > x Kg x Kg + 696PAL = 1.3 energy = 2474  PAL (Patient Activity Level) Activity level Men WomenPAL = 1.55 Inactive energy = 2950 Light Moderate Heavy

26 Behaviour change:  Talking Therapies: Life coaching Cognitive Behavioural Therapy (CBT) Neurolinguistic Programming (NLP) Emotional Freedom Techniques (EFT) Hypotherapy Hypnobanding etc

27 Pharmaceutical Strategies Old Medications: Am-Bar (amphetamine + Barbiturate), Phentermine, Rimonabant, Sibutramine etc Current licensed medications: Pancreatic lipase inhibitors Orlistat - Xenical Alli – otc

28 Some medications cause weight gain – action often unknown

29 Common mistakes All sugars are the same (4kcal/g) i.e., sucrose = fructose etc  Coco pop straws 34g/100g = 2 finger kitkat  Fruit juice approx 9g/100mls All fats (satd/polyunsatd/monounsatd) are the same (9kcal/g)  Jordan’s Country Crisp Cereal: 28.5g/100g = McDonalds McBacon Roll  Thick pork sausages: 20.3g/100g Alcohol (think of each drink as a chocolate bar!) High fat foods vs Low fat foods Premium vs Economy ranges vs Home cooked food: Premium - likely to have high fat and high sugar (high calories) Economy - likely to have high salt Home cooked - likely to have high fat (depends on how it is cooked) ?better

30 Rotherham Town & Demographics 252,000 population 5.2% of the population from BME communities Life expectancy (women & men) - below the national average 2008 – 68th most deprived out of 354 English Districts

31 MATERNAL OBESITY

32 Facilities offered by RIO: Job DescriptionRole Health Trainer Motivational interviewing Healthcare assistant Weighing & measuring. Follow up care Obesity Specialist Nurse Initial triage. Basic nutrition & advice Dietician Specialist intervention. Pre/post surgery “Cook & Eat” Cooking skills and nutrition Exercise Therapist Personal exercise programme (on-site gym) Talking Therapists CBT, NLP, EFT, life-coaching, hypnotherapy GPwSI Pharmacotherapy Pre-camp assessments (children) Pre-surgery assessments (adults) Admin supervisor Liaise with referrers & service providers Clinical Manager Managing service Education room/library Resource room, group work Other consultants Eg, pre-conception care

33 RIO Venue: Doncaster Gate Clifton Medical Centre Doncaster Gate Doncaster Road Rotherham, S65 1DA

34 Weighing and Measuring

35 Multi-use rooms: One-to-one dietetics “Cook & Eat”  RIO Education room  Resource room  MDT meetings  Exergaming  Group sessions

36 Fully equipped on-site gym

37 Talking therapies

38 Reducing local waist!

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40 Results so far:  Tender began April 2009  Launch of serviceSep 2009  Official RIO launchNov 2009 In July 2011 a RIO internal audit showed at that time:  Referrals to date >2890 adults children  1111 adults + 94 children already completed the RIO programme During the 2010/11 year:  96% adults lost weight and 71% met or did better than targets  72% children met target of weight maintenance/loss  Cumulative weight loss = 5.3 tons!  Average (adult) weight loss of 8.3kg (18.3lb)  50% reduction in anticipated numbers for bariatric surgery referral

41 Impact of referral patterns for bariatric surgery (tier 4):  Referral patterns prior to April 2009: approx 100 referred via GP and 50 operations considered suitable and proceeded to surgery  Surgery rates after April 2009: Anticipated (in 2008): 56 (09/10), 67 (10/11), 78 (11/12) Actual: less than 50 referred and performed each year (just 33 in 2010/11)  Conclusions: Tier 3 primary care based MDT specialist service triage: reduces inappropriate referrals reduces numbers of procedures performed

42 Long term development  Research & training centre√  Extended hours√  Role in pre- & post- operative surgery√  OSA screening √  Outreach clinics + target children  Primary care bariatric surgery  Advertising service  Offer service to neighbouring PCTs

43 The Health Village Doncaster Gate Hospital Doncaster Road Rotherham S65 1DA


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